Nac Guide

Evidence-Based Practice
Autism in the Schools

a guide to providing appropriate
interventions to students with
autism spectrum disorders
Copyright 2009 National Autism Center

All rights reserved.
41 Pacella Park Drive
Randolph, Massachusetts 02368
No part of this publication may be reproduced without the prior written permission of the National Autism Center.
To order copies of this book, contact the National Autism Center at 877-313-3833 or info@nationalautismcenter.org.
iii }
Table of Contents
Acknowledgements
vii
Forward
viii
Introduction
The Importance of Evidence-based Practice. . . . . . . . . . . . . . . . . . .
Outline of Chapters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Chapter 1} Autism Spectrum Disorders. . . . . . . . . . . . . . . . . . . . 3
Chapter 2} Research Findings. . . . . . . . . . . . . . . . . . . . . . . . 3
Chapter 3} Professional Judgment. . . . . . . . . . . . . . . . . . . . . . 4
Chapter 4} Values Preferences of Families . . . . . . . . . . . . . . . . . . . 6
Chapter 5} Capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Appendix} Findings and Conclusions of the National Standards Project. . . . . . . 9
References
Understanding Autism Spectrum Disorders

Historical Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
11
11
Defining and Diagnosing Autism Spectrum Disorders. . . . . . . . . . . . . . . 13

Misperceptions About ASD . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Autism Today: Current Facts. . . . . . . . . . . . . . . . . . . . . . . . . . 15
What Does Autism Look Like?. . . . . . . . . . . . . . . . . . . . . . . . 16
Autistic Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Aspergers Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Pervasive Developmental Disorder Not Otherwise Specified. . . . . . . . 22
Retts Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Childhood Disintegrative Disorder . . . . . . . . . . . . . . . . . . . . 24
Autism Across the Lifespan . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Differential Diagnoses and Co-morbid Conditions . . . . . . . . . . . . . . . . 27
Frequently Occurring Diagnoses and Conditions . . . . . . . . . . . . . . . 29
Anxiety and Depression. . . . . . . . . . . . . . . . . . . . . . . . . 29
Attention Deficit Hyperactivity Disorder . . . . . . . . . . . . . . . . . . 30
Obsessive-Compulsive Disorder. . . . . . . . . . . . . . . . . . . . . 31
Psychotic Disorders. . . . . . . . . . . . . . . . . . . . . . . . . .
32
Bipolar Disorder and Oppositional Defiant Disorder . . . . . . . . . . . .
33
Final Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Recommended Readings
35
References
36
{ iv
Research Findings of the National Standards Project
37
Established Treatments. . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Antecedent Package . . . . . . . . . . . . . . . . . . . . . . . . . . .
40
Behavioral Package . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Comprehensive Behavioral Treatment for Young Children . . . . . . . . . . .
46
Joint Attention Intervention. . . . . . . . . . . . . . . . . . . . . . . . . 48

Modeling. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
50
Naturalistic Teaching Strategies. . . . . . . . . . . . . . . . . . . . . . . 52

Peer Training Package. . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Pivotal Response Treatment . . . . . . . . . . . . . . . . . . . . . . . .
58
Schedules. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Self-management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Story-based Intervention Package . . . . . . . . . . . . . . . . . . . . . . 66
Final Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
69
References
70
Professional Judgment and Data-based Decision Making
73
Integrating Information About the Student . . . . . . . . . . . . . . . . . . . . 74

Awareness of Additional and New Research Findings . . . . . . . . . . . . . . . 75
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
78
Setting Goals and Defining Target Behaviors. . . . . . . . . . . . . . . . . . . 80

Setting Goals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Defining Target Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . 82
Procedures for Collecting Data . . . . . . . . . . . . . . . . . . . . . . . .
83
Frequency Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Time Sampling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Duration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Latency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Additional Data Collection Considerations . . . . . . . . . . . . . . . . . . 89
Using Data to Establish Baselines. . . . . . . . . . . . . . . . . . . . . . . . 90
Intervention Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
91
Graphing Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
v }
Visual Analysis of Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Calculating the Percentage of Overlapping Data Points. . . . . . . . . . . . . 98
Challenges in Visual Analysis . . . . . . . . . . . . . . . . . . . . . . . . . 102
Is the Intervention Effective?. . . . . . . . . . . . . . . . . . . . . . . . . 105
Final Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . .
108
110
References
110
Incorporating Family Preferences and Values

Into the Educational Process
111
Supporting Family Involvement in Evidence-based Practice. . . . . . . . . . . . 113

Cultural Variables. . . . . . . . . . . . . . . . . . . . . . . . . . . .
114
Socioeconomic Status. . . . . . . . . . . . . . . . . . . . . . . . . . . 116

Employment and Family Issues. . . . . . . . . . . . . . . . . . . . . . . 117
Severity of Symptom Presentation. . . . . . . . . . . . . . . . . . . . .
118
School Factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

Social Validity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
119
Recommendations for Incorporating Family Preferences and Values. . . . . . . .
120
Data Collection. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
121
Ongoing Communication . . . . . . . . . . . . . . . . . . . . . . . . . 131

Parent Education and Training. . . . . . . . . . . . . . . . . . . . . . . 131
Tackle Barriers to Family Participation. . . . . . . . . . . . . . . . . . .
133
Inform Families of Choices and Options. . . . . . . . . . . . . . . . . . . 134

Address Conflicting Views . . . . . . . . . . . . . . . . . . . . . . . .
135
Establish Appropriate Family Supports . . . . . . . . . . . . . . . . . . . 136

Support Parents in Generalizing Skills. . . . . . . . . . . . . . . . . . . . 137
138
Case Example . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
142
References
143
{ vi
Building and Sustaining Capacity to Deliver Treatments

that Work
145
Producing Systemic Change . . . . . . . . . . . . . . . . . . . . . . . . . 148

Step 1: Establish the Planning Team . . . . . . . . . . . . . . . . . . . .
149
Step 2: Problem Clarification and Needs Assessment . . . . . . . . . . . . . 154

Step 3: Evaluating Outcomes. . . . . . . . . . . . . . . . . . . . . . .
168
Step 4: Developing a Training Plan. . . . . . . . . . . . . . . . . . . . . 172

Step 5: Sustainability. . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Unique Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Case Study: Developing Capacity Elizabeth Public School District . . . . . . . . 178
180
181
References
181
Appendix
Findings and Conclusions of the National Standards Project
182
vii }
Acknowledgements
We are grateful to the many individuals and organizations who supported the development of this manual.
Production and distribution have been made possible through a generous gift from the American Legion Child
Welfare Foundation, Inc. Thanks to their support, the National Autism Center has delivered thousands of free copies
of the manual to educators across the country serving students with Autism Spectrum Disorders.
We also wish to express our gratitude to the Niel M. Wreidt 2003 Revocable Trust for the financial support that
allowed us to develop this manual.
This manual could not have been developed without the contributions of its primary authors. We thank: Laura Fisher,
Psy.D., for her comprehensive examination of Autism Spectrum Disorders (Chapter 1); Dipti Mudgal, Ph.D., BCBA, for
her extensive review of interventions that have solid research support (Chapter 2); Hanna Rue, Ph.D., for her thoughtful examination of professional judgment and data-based decision making (Chapter 3); Melissa Hunter, Ph.D., for
her sensitive consideration of strategies for incorporating family input into decision making (Chapter 4); and Susan
Wilczynski, Ph.D., BCBA, for her analysis of methods of producing systemic change to enhance evidence-based
practice in the schools (Chapter 5). Dr. Wilczynski also served as a secondary author for Chapters 14.
Finally, we appreciate the in-kind support provided by May Institute. Without the support of its talented communications team, this manual would be visually unappealing and hard to read!
Susan M. Wilczynski, Ph.D., BCBA

Executive Director
Eileen G. Pollack, M.A.

Director of Publications and Media Relations
National Autism Center

Editor
National Autism Center

Editor
{ viii
Forward
The National Autism Center is dedicated to serving children and adolescents with Autism Spectrum Disorders (ASD)
by providing reliable information, promoting best practices, and offering comprehensive resources for families,
practitioners, and communities. The National Autism Center initiated the National Standards Project to conduct a
comprehensive review and evaluation of existing research into treatments for children and adolescents with ASD.
The resulting National Standards Project Report was published in 2009 to share these findings. (See Appendix for the
Findings and Conclusions report.)

We offer this educator manual to help fulfill the National Autism Centers mission to advocate for evidence-based
practice, and to assist front-line interventionists as they select and implement the most effective research-supported
treatments for ASD.
Introduction
The Importance of Evidence-based
Practice
The evidence-based practice movement began in medicine in the 1990s.
While research had led to advancements in the medical treatment of
patients, physicians were not always aware of these advancements. In some
cases, physicians continued to use medications or medical procedures that
were no longer considered appropriate. In other cases, physicians were
unaware of newer medications or medical procedures that would lead to better outcomes for their patients.
Physicians are not alone in their need to stay current with advances in research and
best practices in their fields of expertise. A broad range of health and school professionals also face this problem. While keeping up with research is challenging, we are
all obligated to do so in order to provide the most appropriate and effective services to
the students we serve. In fact, federal legislation regulating the provision of services in
schools is filled with references about the need to employ research-supported treatments (Individuals with Disabilities Education Improvement Act, 2004; No Child Left
Behind, 2002).
The National Autism Center has developed this manual as a means of promoting
evidence-based practice for Autism Spectrum Disorders (ASD) in the schools. Why?
Because we know that evidence-based practice is in the best interest of the student
and that it is most likely to produce positive outcomes with this population. The information presented herein is meant for all front-line interventionists who work in
school settings.
Although research findings are essential, they are not the only component of
evidence-based practice. Evidence-based practice requires the integration of research
findings with other critical factors.
1 } Evidence-based Practice and Autism in the Schools
These factors include:

Professional judgment and data-based decision making
Values and preferences of families, including the student on the autism spectrum
whenever feasible
Capacity to accurately implement interventions
This definition of evidence-based practice is applied to school settings throughout this document. Evidence-based practice is complex and requires both ongoing
communication and respectful interactions among all stakeholders. Even when a
list of effective treatments is identified, collaboration is the key to achieving the best
outcomes. To that end, we have provided examples involving a broad range of professionals and support staff throughout the manual to illustrate the points we make.
We have organized this manual in a progressive fashion. We recommend beginning with the chapter describing ASD and ending with the chapter on building capacity.
Although some chapters may be perceived as more relevant to some school personnel
(e.g., an administrator may be drawn to the chapter on building capacity), we believe
it is important for all school personnel to be familiar with all factors that contribute to
evidence-based practice for ASD. For example, we anticipate that even experienced
professionals will benefit from the discussion about complex diagnostic concerns for
this population.
About our Terminology:

Our goal has been to make this manual as user-friendly as possible. Therefore, we have tried whenever possible to avoid using jargon, and we have defined terms when necessary.
It is important to clarify our use of terminology regarding school personnel in these pages. We
often use the terms educators, front-line interventionists, school staff, and school personnel interchangeably. Although the examples we provide include paraprofessionals, teachers, and
support service staff, we often apply the more generic terms because any of these individuals may
be represented in the examples.
National Autism Center { 2
Outline of Chapters
Chapter 1} Autism Spectrum Disorders
Most readers of this manual will already have some understanding of Autism
Spectrum Disorders (ASD). But autism and related disorders are complex, and we all
benefit from considering just how broad the spectrum can be. Experience with young
students with severe autism is not the same as understanding adolescents with
Aspergers Disorder. Further, an alarming number of students with ASD are misdiagnosed with alternate disorders for years before receiving the correct diagnosis. Finally,
some students on the autism spectrum should also be diagnosed with one or more
additional disorders. Correct diagnosis is essential for developing interventions that will
help your students reach their potential.
We begin our manual on Evidence-based Practice and Autism in the Schools by
reviewing the defining and associated features of ASD. In Chapter 1, we also consider
variables that should be examined when making differential diagnoses for individuals
demonstrating symptoms often associated with ASD.
Chapter 2} Research Findings

Everyone wants to use treatments that work. Yet identifying effective interventions
can be challenging. Consider this: treatments for which no well-controlled research
has been published are often described as evidence-based practice. This can make it
extremely difficult to know which treatments have research showing they are effective,
and which do not.
We recognize that translating research into practice is complicated. That is why we
have created this manual as a tool to help you know which interventions have strong
evidence of effectiveness. The National Autism Centers National Standards Project
identifies the level of research support available for treatments often used with schoolaged individuals on the autism spectrum.
In the Findings and Conclusions report of the National Standards Project, the term
Established Treatments is applied to any interventions with sufficient research to
show they are effective. Eleven Established Treatments are identified in Chapter 2. We
describe each one detail and provide illustrative examples to clarify the uses of these
interventions.
Chapter 3} Professional Judgment

Evidence-based practice is a complex process that requires the knowledge and
skills of well-trained professionals. Therefore, your professional judgment is extremely
important in this process. In your work, you are presented with a broad array of treatment options available to support students on the autism spectrum. Even if you restrict
your choices exclusively to treatments that have produced favorable outcomes in
research, you will need to select among the field of 11 identified in the Findings and
Conclusions report.
Your experience working with a specific child with ASD, your understanding of interventions that have been effective in the past, and your awareness of the environment
in which the treatment would be implemented are all critical to helping you identify
which of these 11 Established Treatments might be most useful.
Since research is ongoing and best practices evolve, your professional judgment
extends to your awareness of additional research support beyond those studies
reviewed in the Findings and Conclusions report.
For example:
The National Standards Project reviewed articles published before the fall of 2007.
We are happy to report that additional research has been conducted and published
since that date. As a result, you may be aware of more recent, well-controlled studies that strongly suggest more research support for an intervention identified as
an Emerging Treatment in the Findings and Conclusions report. Armed with this
knowledge, your judgment may lead you to place that treatment under consideration along with any of the Established Treatments.
There may be some symptoms that co-occur with ASD that are not associated
with any Established Treatments. For example, some adolescents with Aspergers
Disorder may experience co-morbid psychiatric disorders (e.g., anxiety disorders or
depression). There are no treatments specifically addressing anxiety and depression
that fall into the Established Treatments category in the Findings and Conclusions
report. However, there are treatments for anxiety and depression for individuals
who are not diagnosed with ASD. Your awareness of this important literature should
absolutely assist in treatment selection.
Like other evidence-based practice guidelines, the National Standards Project

followed strict inclusionary and exclusionary criteria. How did this affect the
outcomes? Perhaps Facilitated Communication can serve as an example. The
National Standards Project excluded a
large number of studies on the treatment
of Facilitated Communication because
they involved {a} adults 22 years of age or
older, or {b} individuals with infrequently
occurring co-morbid conditions, or {c} adult
facilitators (as opposed to the individuals
with ASD). Although Facilitated Communication was classified as an Unestablished
Treatment in the Findings and Conclusions report, as a professional, you may be
aware that a large number of professional
organizations have developed resolutions
advising against the use of Facilitated
Communication. These resolutions are
often related to concerns regarding
immediate threats to the individual civil
and human rights of the person with
autism (American Psychological Association, 1994). Your professional judgment
is likely to play a role in treatment selection
in this case, as one example.
Professional judgment can also be
important when considering an intervention
identified as an Established Treatment in the
Findings and Conclusions report. You may
seek out more detailed information in the

literature to help guide appropriate treatment
selection.
For example, lets say a young boy with
ASD has a history of becoming prompt
dependent. You might select Schedules to
help him independently move from one task
to another. Then you might select prompts
that are easier to fade as opposed to prompts
that are more difficult to fade. Although
schedules and prompting procedures are each
identified as an Established Treatment in the
Findings and Conclusions report, your professional judgment as a front-line interventionist
is essential in structuring environments that
best promote independent learning.
Initial treatment selection is only one part
of the process of engaging in evidence-based
practice. In order to be confident that an intervention is effective with a specific student,
it is necessary to collect data. These data
should be collected in a way that allows you
to determine if the intervention is effective.
Data will also let you quickly make changes to
treatments if an intervention is not producing
desired improvements for your students.
Chapter 3 offers a more complete discussion of the importance of professional
judgment and the role data collection plays in
this process.
Chapter 4} Values and Preferences of Families

Family members and/or the individual with ASD should participate in intervention
selection to maximize outcomes. The annual review of the Individualized Educational
Plan (IEP) serves as one opportunity to discuss the comprehensive goals to be met so
that the student with ASD can reach his academic potential and participate in meaningful ways in the community. But setting these goals is only the starting point in the
conversation that should occur between family members, the student with ASD, and
school professionals. To achieve the best outcomes, efforts should be made to build
consensus about the treatment approaches used to meet the IEP goals.
There are several ways in which treatment selection is undermined if the input of
family members and/or the individual with ASD is not sought, or is ignored. For example, family members often seek additional supports beyond those offered within school
systems. Behavior specialists, speech-language pathologists, occupational or physical
therapists, and other professionals may provide therapeutic services outside the school
setting. These professionals may have already attempted to implement any number
of treatments that did not produce favorable outcomes. Without seeking the familys
input, school professionals may select treatments that have already been shown to
be ineffective with a specific child. (See Chapter 5 for discussion of the importance of
data-based decision making as a component of professional judgment.)
It is also important to understand how the cultural values and preferences of a family may conflict with the implementation of one treatment or another. For example, in
certain cultures, it is not appropriate for children to make direct eye contact with adults.
Despite the fact that teaching a child to make and maintain eye contact is often one of
the first skills addressed in Comprehensive Behavioral Treatment for Young Children,
family members may object to this skill being taught. Often, a compromise might be
reached if an open and honest dialogue occurs. (For example, the child will make eye
contact with adults in the school setting, but no efforts will be made to teach her to
make eye contact in other settings.) Conversely, the team may make the decision to
begin the intervention without directly

teaching eye contact and then set a date
to reconsider the issue if the data show
the child is making little progress.
To expand your use of strategies for

incorporating the values and preferences
of families, we encourage you to read
Chapter 4.
There are many barriers that could

undermine parental participation in the
educational process. These barriers do
not have to be insurmountable if schools
seek to identify and address them. For
example, additional supports should be
provided for families facing challenges
associated with transportation, child
care, language barriers, or difficult work
schedules. We offer strategies for gathering information from families that will
allow you to create a positive and inclusive environment for the entire family.
Chapter 5} Capacity
The individual with ASD is a member of the family, and his values and
preferences must also be taken into
consideration whenever feasible. For
example, an adolescent boy who would
benefit from an improvement in his
social relationships might select a less
intrusive intervention (such as Social
Stories) over a more intrusive procedure that sets him apart (such as Peer
Training Package). Certainly, his opinion
is relevant in selecting between these
two treatments, and will likely have an
impact on outcome.
Lets say your school makes the

decision to implement one of the interventions identified as an Established
Treatment in the Findings and
Conclusions report. Does this automatically mean you are about to engage in
evidence-based practice for ASD? We
would argue that you are notthat is,
not until you have built the capacity to
implement the intervention with a high
degree of treatment integrity. Further,
even after you have begun to implement
the intervention correctly, you must
ensure the intervention is sustainable.
We already know that selecting
treatments should involve {a} an understanding of research findings, {b} input
from qualified professionals, and {c}
input from families, including the student
whenever possible. However, when your
school makes decisions about implementing an intervention, its important
to ask, If we feel strongly enough
that this intervention should be implemented with one child, should it also be
implemented with more children with ASD

who exhibit similar needs? When selecting one of the Established Treatments, the
answer will almost always be yes.
Selecting treatments for more than one
child often involves making systemic changes
within the school system. This typically begins
with problem clarification. You need to answer
three questions: What do we need to accomplish? Who is responsible for planning for the
new treatment? Who will evaluate the effectiveness of the new treatment?
When decisions are made for a specific
child, these questions are often answered by
a small team of individuals who work with or
care for the child. When decisions are made
for a school system, it is important to include
a broader range of professionals, as well as
families, into the decision-making process.
Paraprofessionals, other support staff, psychological services, allied health professionals,
and administrationin addition to teachersshould all be included in the planning
and evaluation of any new treatment that is
being adopted broadly (across students and
settings).
The planning and evaluation team will also
need to make decisions about the scale of
the change (e.g., a classroom, a grade level,
or a school) and the groups for which the

new treatment should be considered (e.g., All
children? All children with ASD? Children in a
particular age group or developmental level?).
Next, the team must consider all aspects
of the system that may be affected by this
change. For example, will the curriculum
need to be changed? What are the settings in
which the treatment will be delivered? Who
will deliver the treatment?
Before beginning training, a needs

assessment should be conducted to
identify the following barriers:
Differences between the existing and proposed interventions
Additional time required to implement new
treatments
Treatment acceptability
History of treatment delivery
Organizational climate
The planning and evaluation teams
responsibilities do not end with the needs
assessment. They must also operationally
define the intended outcomes. This may
involve specifying the goals for a classroom,
grade level, and/or school system. In addition
to clearly defining the goals for the affected
system, the goals for the target population
must be defined so that they are specific, observable, and measurable. Both immediate and long-term goals must be considered.
Finally, the planning and evaluation team must develop a written plan for implementing the intervention. That plan will clearly specify the roles and responsibilities of
both the team and the professionals responsible for implementing the new treatment.
Developing the plan is an extensive process that is outlined in Chapter 5.
Appendix} Findings and Conclusions of the

National Standards Project
The Findings and Conclusions report of the National Standards Project is published
in the appendix of this manual. We hope you will find this to be a valuable resource.
The authors and editors received no remuneration for recommendations for books and other
publications made throughout this manual.
References}
American Psychological Association (1994).

Resolution on facilitated communication by
the American Psychological Association.
Adopted in Council, August 14, 1994, Los
Angeles, Ca. Available at http://web.syr.
edu/~thefci/apafc.htm (assessed March 4,
2009).
Individuals with Disabilities Education
Improvement Act of 2004, Pub. L. 108-466.
No Child Left Behind Act of 2001, 20 U.S.C.
6301 et seq. (2002).
Understanding Autism
Spectrum Disorders
Historical Perspective
There has been tremendous progress made in the field of autism over the
last 50 years. While it was once a syndrome that was rarely discussed in
public, we find information about Autism Spectrum Disorders (ASD) all
around uson television and radio, websites and Internet searches, public
service announcements, and in the views of celebrities sharing their stories.
Even the President of the United States is now discussing the importance of
autism diagnosis, cause, and cure, and he has earmarked federal dollars for
research and treatment initiatives that will be instrumental in furthering the
field in the years to come.
Before discussing the current state of autism, however, lets briefly review the history of this disorder and what we have learned over the years.
In 1943, a doctor named Leo Kanner began observing a group of children who were
previously thought to have mental retardation. He noticed that these children had difficulty developing speech, and did not socially interact with their peers. He also noted
that these children engaged in ritualized and/or repetitive behaviors to the exclusion of
other activities. These children had difficulties with transitions, and did not like changes
in their routines or schedules. Some of them experienced regressions in their functioning over time, losing skills that had been established previously. We know Kanners
description will be familiar to you if you serve children on the autism spectrum.
At the time, treatment for autism was very limited. Most of these children were
placed in institutions, far from the public eye, to live out their lives. Professionals
commonly held the view that refrigerator mothers were responsible for the symptoms observed in these children. Deficits in the childrens functioning were assumed
to be linked to poor attachment and/or absentee parenting (Bettleheim, 1967). Because
parents were often blamed for their childrens disorders, many experienced great
shame for having a child with ASD.
Much has changed in the last five decades. We now know that autism is most likely
caused by a combination of genetic and environmental factors. Although we would like
to think that parents are no longer blamed, all-too-frequent examples demonstrate how
autism is still widely misunderstood. One example is a nationally known radio personality who recently stated that autism was a fraud, a racket and that a child diagnosed
with ASD is probably a brat who hasnt been told to cut the act out. Lets hope that
some day parents will no longer face this kind of discrimination.
Around the same time that Kanner was identifying symptoms of autism, pediatrician
Hans Asperger was studying another group of children (Wing & Gould, 1979). These
boys and girls were also having problems in social interactions with their peers. Like
their counterparts, they exhibited behavioral problems commonly seen in children with
autism. However, this group of children did not have deficits in speech and language
formation. In fact, these children often spoke early and frequently. They also did not
display deficits in adaptive functioning. In other words, these children could feed themselves, dress themselves, participate in their personal care, and function independently
in the community. Unlike the group that Kanner observed, most of these children did
not have lowered cognitive abilities. They were often very bright and had specific areas
of interest in which they could amass large amounts of information.
Unfortunately, Aspergers research was not discovered until three decades later.
It was reintroduced to the field when other individuals interested in ASD began
questioning the diagnostic criteria that were used at the time. His work has made a
tremendous difference in the way we have come to view and understand the autism
spectrum.
Defining and Diagnosing Autism

Spectrum Disorders
In 1994, the Diagnostic and Statistical Manual of Psychiatric Disorders
(DSM-IV) went through a complete overhaul (American Psychiatric
Association). The diagnostic criteria for Pervasive Developmental Disorders
(PDD), commonly referred to as Autism Spectrum Disorders (ASD), were
reviewed and revised to include aspects of both Kanners and Aspergers
work.
There was also additional research on another group of children who seemingly
met strict criteria for autism, but did not have severe deficits in cognitive functioning.
As a result, these children were labeled as having high functioning autism (Ozonoff,
Dawson, & McPartland, 2002). Steps were then taken to establish new diagnostic
criteria which considered the changes and variability observed in children with ASD.
The current version of the DSM (DSM-IV-TR, 2000) includes five major
diagnoses that fall under the Pervasive Developmental Disorder (or ASD)
umbrella:
1. Autistic Disorder
2. Aspergers Disorder
3. Pervasive Developmental DisorderNot Otherwise Specified (PDD-NOS)
4. Retts Disorder
5. Childhood Disintegrative Disorder
Of the five, two of these disorders (Retts Disorder and Childhood Disintegrative
Disorder) are extremely rare, and you are unlikely to see these cases in schools. In fact,
they are sufficiently different from the other three disorders that there is disagreement
in the field about whether or not they actually belong on the autism spectrum.
The other three diagnoses are more common, and you are very likely to come in
contact with children and adolescents who meet criteria for one of the three disorders
in your daily school interactions with students.
As our understanding of ASD has evolved over the years, so too has the way we
diagnose and treat children with ASD. It can be viewed as a lifelong syndrome that is
usually diagnosed in early childhood and continues through adulthood. Although there
is currently no cure for ASD, impressive and long-term life outcomes can occur when
children receive early and intensive behavioral interventions.
In fact, a percentage of children fall off the spectrum following intensive intervention and re-evaluation by autism specialists (USA Today, May 8, 2009, Some kids
with autism can recover, study suggests). These kinds of improvements reinforce
the critical importance of early identification and treatment. As a field, we are continually improving the way we identify children so we can streamline them into specialty
services (Gupta et al., 2006; Kabot, Masi, & Segal, 2003; Sigman, Dijamco, Gratier, &
Rozga, 2004).
Misperceptions About ASD

When people think of ASD, they often conjure up images of individuals with
severely impaired language who are living in institutions, similar to Dustin Hoffmans
character in the movie Rainman. Working in the schools, however, you know this is
typically not the case. While it is true that some children remain nonverbal, many
children with ASD have some form of verbal communication skills. They often develop
these skills as a result of treatment provided by school and allied health professionals
who are committed to evidence-based practice.
Another commonly held assumption that has evolved over time is that all children
with ASD have intellectual disabilities. It is true that, in the past, over 80% of children
diagnosed with ASD also met criteria for mental retardation. However, with early diagnosis and access to effective treatment, these numbers are decreasing (Chakrabarti &
Fombonne, 2005).
Autism Today
There has been much discussion as to why the
rate of autism has been steadily increasing since
the 1990s. One reason is linked to the change in
Current facts about autism:

It affects 1:150 children nationwide (Centers for
Disease Control and Prevention).
diagnostic nomenclature in 1994. At that time, the

diagnostic criteria for autism expanded to include
It can be found in all cultures of the world, and
children who were not previously considered on
does not discriminate based on race, socio-
the spectrum.
economic status, education of parents, or other

demographic variables (Wong, Hui, & Lee, 2004;
Studies have shown that, despite this change
Howlin & Asgharian, 1999).
in diagnostic criteria, the number of diagnosed

cases of ASD is much higher than expected
It is three to four times more common in boys

than in girls.
(Johnson & Myers, 2007). Many researchers

believe the increase in the number of cases of
autism worldwide is due to a combination of
It currently has no known cause or cure.
genetic and environmental factors (Folstein &

Rosen-Sheidley, 2001).
Researchers are working diligently to seek
answers for families about the cause of autism.
What Does Autism Look Like?

This section describes each of the five diagnoses for ASD in greater detail. As you
study the different features and characteristics associated with these diagnoses, you
will be able to more clearly identify the similarities and differences between autism and
its related disorders.
Autistic Disorder
As many front-line interventionists know, autism is characterized by severe difficulties in communication, socialization, and behavior (Klinger, Dawson, & Renner,
2003). What this means for individual children varies based on each ones cognitive
ability, communication skills, and adaptive functioning. When a child is diagnosed
with Autistic Disorder, or autism, he or she has met at least six out of 12 criteria,
with at least two criteria in the social domain, based on the DSM-IV-TR (APA, 2000).
In addition, symptoms must be present before the age of three, and must affect
the childs functioning in more than one area of concern (i.e., home, school, or community). Moreover, symptoms cannot be better accounted for by other disorders
associated with attention, behavior, thought processes, medical concerns, or mood.
Examples of symptoms of Autistic Disorder in the communication domain

include:
The child must have a delay in language.
The child does not compensate for a delay in language by using strategies like
gestures to communicate.
The child may exhibit problems with language, once language starts to develop.
For instance, he may engage in repetitive language, or scripts, to communicate.
He may repeat phrases he has heard on television or from his parents or friends.
The child may immediately echo the speech of another individual.
The child often has trouble initiating and maintaining conversations with peers. It
may seem like she is talking at someone instead of with someone. She may also
find it difficult to start and stop conversations.
The child often has significant difficulty with, or cannot respond to, open-ended
questions.
The child may exhibit significant delays in play skills. Typically, as a child ages,
he should move from basic imitation to more complex make-believe play (Lifter,
2008). However, he also needs to be able to interact with peers when they
playsomething which children on the spectrum often do not do spontaneously.
Examples of symptoms of Autistic Disorder in the social domain include:

The child may poorly modulate eye contact. She may be able to look at family
members, but not at peers. Or she may be able to make eye contact, but only
fleetingly or under certain conditions.
The child may have a blank expression, or difficulty expressing a range of facial
expressions. Some children with autism appear to be happy and smiling all the
time. While this may seem to be a positive attribute, it can be misleading or
confusing when a child who has a happy expression kicks or bites out of anger or
frustration.
The child may be capable of displaying many different facial expressions, but still
fails to convey his emotional state to others. For example, a child may not physically orient to another person to communicate his mood. He may then become
frustrated that others are not picking up on his moods (even though he is not
directing his facial expressions to help other children and adults understand his
point of view). In extreme cases, children may actually turn their bodies away
from you when interacting. This can be quite confusing for the conversational
partner.
The child may have difficulty incorporating nonverbal communication in his
speech or social interactions. Most people talk with their hands, make subtle
movements with their eyes and head to indicate the conversations should
continue or end, and engage in other slight nonverbal gestures as a way of communicating. In fact, 80% of communication is nonverbal in nature! Most children
with autism do not know how to use gestures effectively. These children may not
realize the significance of specific gestures, and may therefore use them inappropriately. Unfortunately, many children with autism have a difficult time reading
nonverbal cues. As a result, they may be ostracized by peers due to their inability
to manage social interactions.
The child may have significant problems making and maintaining friendships. A
younger child with autism will often play alone or have difficulty joining group
activities. She may also engage in earlier stages of play, such as parallel play,
when her peers engage in more interactive play. An older child may not have a
best friend or social group. He may prefer solitary activities such as playing
video games all day, or setting up elaborate play schemes with action figures that
cannot be altered by others.
The older child with autism may not understand personal boundaries, and will
either stand too close or too far away from peers. Overall, establishing friendships is difficult.
The child may have difficulty with social or emotional reciprocity, which can be
loosely translated as the give and take of an interaction. She may be more successful when she can set up the interaction to accommodate her needs. Some
common challenges with reciprocity for children with autism include:
Turn-taking activities, particularly for younger children.
Expressing empathy when others are upset or distressed. This becomes
more problematic as children age and emotional and social concerns move to
the forefront.
Offering comfort when another person is crying, or joining in when someone
is extremely happy.
Sharing accomplishments or seeking praise.
Understanding their role in relationships. This can be the biggest challenge
for children on the spectrum, as they often do not realize how their behaviors
affect those around them.
Knowing how to alter their behavior to better meet the needs of others.
Examples of symptoms of Autistic Disorder in the restricted, repetitive,

nonfunctional patterns of behavior, interests, or activities include:
The child may exhibit strong interests in a specific topic or toy. Children with
autism have been known to have extreme interests, such as memorizing train
schedules or dates in history, or categorizing all aspects of aquatic life. They may
have extremely well-developed memory skills, and be able to easily recall things
that occurred many years ago. Many children gravitate to numbers, letters, and
colors in their play and communication with others. Some children become
fixated on videos such as Thomas the Tank Engine, watching segments of the
movie over and over.
The child may have extremely rigid ideas about time, travel, and daily routines.
He might become highly agitated if his routine is altered. It is not uncommon for
parents to report that their child becomes very upset when the family drives a
different route home from school one day.
The child often thrives on structure, and can have difficulty adjusting when school
vacation starts, or the family moves to a new home. This rigidity can be seen in
a childs play as well. Some children insist that play sequences unfold in a certain
manner, and become annoyed or withdrawn if the play sequence is altered by
peers or adults. Parents also report rigidity around feeding, dressing routines,
and placement of objects around the home.
Probably one of the most obvious symptoms of Autistic Disorder includes the
atypical body movements that are sometimes associated with this disorder.
Although not always indicative of autism, these symptoms are often the first
things people notice in terms of unusual behavior. For instance, some children
really enjoy spinning their bodies in circles for much longer than their peers could
sustain. Other children engage in full or partial body rocking, and may position
their bodies in unusual ways. Children will sometimes run in ritualized patterns
on the playground or in the home. They may walk on their toes or flap their
hands. At times, they may flick their fingers or cross them in unusual ways.
The child may experience sensory challenges, and will be either over- or undersensitive to temperature, texture, smell, or sound. It is not uncommon for the
child to refuse to wear specific types of clothing or sleep on sheets that are not
made of a specific material.
The child often engages in unusual play-based behaviors. She will line up her
toys, categorize them, or place them in various positions that cannot be altered.
Some children enjoy watching objects fall, and will repetitively drop objects such
as balls, water, sand, etc. Other children enjoy spinning items, and will spin toys,
plates, forks, lids, or other things that are not meant to be spun.
The child may visually examine his toys or objects in their environments. He may
peer at objects out of the corner of his eye, but also may place them directly in
his field of vision, moving them in and out of that field. Often, a child will flip over
a toy car and flick the wheels while watching them spin, or lie on the floor and
watch the wheels move as he pushes the car.
Aspergers Disorder
In many ways, Aspergers Disorder (also called Aspergers Syndrome) is very
similar to Autistic Disorder. Like the child with Autistic Disorder, the child with
Aspergers Disorder has problems with multiple areas of critical life functioning
which appear in a variety of situations. Whereas Autistic Disorder is characterized by
deficits in all three domains (communication, socialization, and behavior), to qualify
for a diagnosis of Aspergers Disorder, a child does not have an identified history
of communication difficulties early in life. That is, basic receptive and expressive
skills do not appear impaired in children under age five. By definition, children with
Aspergers Disorder do not have a language delay. In fact, they often have a history
of speaking early, and can be quite hyperverbal in their toddler years. They may learn
to read words early as well (i.e., hyperlexia), and may have awed their parents with
their ability to recite things like labels and highway signs.
Although language delays are not identified in young children with Aspergers
Disorder, this does not mean they will not experience significant communication
challenges. As we have already described, communication is complex and involves
not only speech, but nonverbal strategies

and social pragmatic skills. Social pragmatics involves the use of language for a
wide variety of functions (e.g., requesting, informing, promising, etc.). It also
involves the ability to alter language based
on the needs of the listener. Students with
Aspergers Disorder may not provide the
context for a story they are telling, or may
not understand that the quality and content
of speech should be modified across settings (e.g., classroom, lunch room, library,
etc.).
Finally, most people independently learn
certain conventions about holding conversations. They probably read cues suggesting
the person with whom they are communicating has become confused or bored.
They read the expressions of others and
change their own expressions based on
the tone of the conversation. Students with
Aspergers Disorder often have difficulty
learning and applying these rules regulating
conversations.
Similar to their counterparts with Autistic
Disorder, some children with Aspergers
Disorder have incredible memories and
can amass large amounts of data about a
topic of interest. Usually, these interests
are atypical for the age of the child and
can impede his ability to socially connect
with other children. Unfortunately, most
7-year-olds do not want to hear all about the
sinking of the Titanic, the great horned owl

of Minnesota, or how tectonic plates shift in
the geothermal layer of the earth!
Like children with Autistic Disorder, children with Aspergers Disorder are likely to
be challenged by social situations. However,
they often appear more sophisticated than
their counterparts with autism. As a result,
people with whom they come in contact
assume these individuals will follow the
social rules that guide us through a complex social world. However, children with
Aspergers Disorder will likely miss social
cues provided by peers. Their timing may
be off when they initiate an interaction,
and the quality of the interaction is usually different from that of their peers. They
may find awkward ways to interject their
agenda into a social activity. Because many
individuals with Aspergers Disorder have
reduced interest in interacting with others,
they unfortunately get even less experience
developing these social skills.
Children with Aspergers Disorder differ
from children with Autistic Disorder in two
other fundamental ways. First, they do not
have cognitive delays. In some cases, they
may even be intellectually gifted, and may
receive high scores on standardized tests
of intelligence. These children often display
higher verbal skills as compared to nonverbal skills. (Often, the reverse is true in
Autistic Disorder.)
Despite their cognitive strengths, students with Aspergers Disorder often

require accommodations in the classroom in order to successfully manage the
same academic coursework and materials as their peers. They may have difficulties
understanding the abstract nature of some instructions, or may be challenged by
the lack of structure involved in some tasks (e.g., self-directed group activities).
Secondly, children with Aspergers Disorder do not exhibit delays in adaptive
functioning. This means they can bathe, feed, and dress themselves without assistance. They generally do not have difficulty with skills such as making purchases,
using computers, or applying basic rules of safety in public places. They often attend
regular classrooms and can be involved in peer-driven activities.
Pervasive Developmental DisorderNot Otherwise

Specified
Pervasive Developmental DisorderNot Otherwise Specified (PDD-NOS) is an
umbrella term assigned to children who do not meet criteria for either Aspergers
Disorder or Autistic Disorder (Walker et al., 2004). Psychologists diagnose PDDNOS when a child has some symptoms of ASD (4-5 versus 6 or more). In addition,
children who do not have the typical profile but meet a sufficient number of characteristics of ASD (e.g., a child who starts to show symptoms after age 3) would
receive a diagnosis of PDD-NOS.
The most common misconception about a diagnosis of PDD-NOS is that it is
equivalent to a very mild form of autism. Nothing could be further from the truth!
For instance, a child can have 4-5 extremely severe symptoms and meet criteria
for PDD-NOS. In comparison, a child with Autistic Disorder (six or more symptoms)
can display more mild symptoms, and have fewer deficits overall. Therefore, when
formulating plans for students with PDD-NOS, it is often beneficial to think of these
children as having similar levels of difficulties as seen in other ASD diagnoses.
Researchers have increased their focus on the diagnosis of PDD-NOS. They
speculate that PDD-NOS includes a number of different sub-groups that explain
and account for unique clusters of symptoms. Until this issue is resolved, however,
a greater percentage of the students you encounter may carry this diagnosis, as
compared to either Aspergers Disorder or Autistic Disorder.
Retts Disorder
Retts Disorder is also considered a
Pervasive Developmental Disorder, or
an ASD. However, this disorder is much
more severe and life-altering than the
previous three discussed.
The research-supported treatments described in this manual may
be implemented with students with
Retts Disorder. However, the findings
and conclusions were not based on a
review of literature involving individuals
with Retts Disorder. Studies involving children with Retts Disorder and
Childhood Disintegrative Disorder were
not included in the National Standards
Project because these disorders are
not on the autism spectrum, according
to the Centers for Disease Control and
Prevention. Also, the developmental
trajectories are so different for these
disorders that there is controversy in
the field about whether or not they
should continue to be included in the
DSM as Autism Spectrum Disorders.
We provide the following description in
the event you encounter a student who
seems to show some characteristics of
autism, but who also seems very different to you.
Facts about Retts Disorder:

It is characterized by repetitive hand
movements, such as clapping or
wringing of hands, which affect
the purposeful use of the hands.
The hand-to-hand contact occurs
persistently throughout the day and
involves the meeting of the hands in
the middle of the body.
It is caused by a mutation on the
MeCP2 gene in 80% of diagnosed
cases.
It is a very rare disorder, affecting
one in every 10,000 births.
It is more commonly seen in
females, although we now know
that males can also have this genetic
abnormality.
Children with Retts Disorder often
have profound mental retardation, possibly due to slowed brain
development and small head
circumference.
Children with Retts Disorder are
often nonverbal, with significant
delays in all forms of communication (e.g., speech, use of gestures,
and other nonverbal communication
strategies).
Children with Retts Disorder have multiple systemic issues such as gastrointestinal problems, motor problems, and bone density abnormalities.
Seizures are common in children with Retts Disorder. As with all seizure disorders, additional loss of skills may occur if seizure activity is not well-controlled.
Many children with Retts Disorder exhibit air swallowing and sleep apnea, and
have choking responses to food. Because of these multi-system concerns, it is
important that you are well-informed about how to address these issues. When
working with children with Retts Disorder, you may have contact with professionals such as neurologists, gastroenterologists, psychiatrists, developmental
pediatricians, orthopedic specialists, feeding specialists, breathing specialists,
and behavioral specialists.
Increasing motor problems may be evident after the age of 10.
Childhood Disintegrative Disorder

The final disorder on the Pervasive Developmental Disorder continuum is
Childhood Disintegrative Disorder (CDD). As noted previously, the researchsupported treatments we describe in this manual were not based on a review of
literature involving individuals with CDD. We provide the following description of
CDD in the event you encounter a student who seems to show some characteristics of autism, but whose history seems very different to you.
Facts about Childhood Disintegrative Disorder:

It is an extremely rare disordereven more rare than Retts Disorder.
Children with this disorder develop normally during the first two years of life.
At around age 3 or 4 (but up to age 10), these children begin to regress in their
communication, social, and behavioral skills. Children who were verbal lose the
ability to speak; those who were social and outgoing appear to become more
withdrawn and isolated; and adaptive functioning skills such as walking or toilet
training disappear.
The outcome for many of these children is poor, and treatment, although congruent with treatments for autism, is not as effective over time.
Autism Across the Lifespan

The symptoms exhibited by a student with ASD may change over time. A
child who receives speech services at age 3 may face very different communication challenges by the time she reaches her high school years.
Each developmental stage brings its own challenges for all children, and this holds
true for students on the spectrum. You are more likely to see certain symptoms in the
toddler years, but these symptoms may be extremely subtle or non-existent by the
time the student reaches adolescence.
This pattern of development can be very confusing for individuals unfamiliar with the
autism spectrum because they expect the same symptoms to remain fairly constant
over time. In fact, some of these individuals may doubt whether an ASD diagnosis is
warranted due to preconceived notions about what a student with ASD should look
like at certain ages.
Table 1 lists some of the various challenges that students with ASD may face across
the years they are served in the schools. It includes an overview of symptoms commonly observed at different stages in a students life. We recommend sharing this
information with colleagues who may have less experience working with students on
the autism spectrum.
Table 1}
Domain
Social
Development
Communication
Development
Restricted,
repetitive,
nonfunctional
patterns of
behavior, interest,
or activity
Other
Developmental Changes in Students with ASD Across the School Years

Age
Symptoms
Infant/Toddler
May avoid touch

May isolate from groups
An infant may not imitate facial expressions
Toddlers may not laugh in response to parents laughter
Failure to respond to the emotional needs of others
Early School Years
May not engage in social games

May prefer younger children
May appear bossy when playing with other children
Adolescence/
Early Adulthood
Gaps in social skills become even more apparent

Dating challenges
Social challenges sometimes related to issues such as poor hygiene (e.g., rigid adherence to rules
regarding frequency of bathing)
Infant/Toddler
May lack speech

Immediate or delayed echoing of others words
Use of scripted phrases
May not respond to name
Unlikely to use gestures
Early School Years
May sound like little professors who are lecturing on a topic

Conversations are one-sided
May not see how their behavior hurts others
Adolescence/
Early Adulthood
Poor understanding of abstract concepts

Challenges in understanding jokes or slang
May mimic language from television or movies, placing them at risk for problems at schools (e.g.,
say Im going to get a gun and kill him as a means of expressing anger or frustration)
Infant/Toddler
Repetitive motor movements like hand-flapping, finger flicking, rocking, etc.

May line up toys for visual examination
May categorize toys instead of playing functionally with them
Some rigidity in routines
Early School Years
Rule-bound
May create own rules to make sense of the worldthen have a hard time managing when others
violate these rules
Adolescence/
Early Adulthood
May engage in elaborate rituals to avoid motor tics

May obsess for hours about a brief encounter with a peer
Infant/Toddler
Tantrums
Sensitivity to light or sound
Feeding challenges (often associated with texture)
Safety concerns (e.g., may run outside in bare feet into the snow)
Early School Years
Academic concerns
Difficulties with concentration and irritability due to sleep or communication problems
May be disruptive during transitions
May be clumsy in sports activities
Adolescence/
Early Adulthood
Symptoms of depression or anxiety

Acting out
May not understand rules regarding sexual behavior (and may be set up by peers to violate these
rules)
Increased risk for seizures (associated with onset of puberty)
Differential Diagnoses and Co-morbid

Conditions
Our goal in this section is to provide background information on disorders
that are related to ASD in two ways. These disorders can be similar to ASD in
various ways (and may therefore be confused with ASD), or they often occur
along with ASD.
Differential Diagnoses. Some disorders share common characteristics with ASD.
For example, children with ASD can have behavioral concerns, attention and concentration difficulties, mood dysregulation, and medical involvementand all of these
symptoms alter with age. It is not easy to diagnose these children or adolescents
because they do not have classic autism. An ASD diagnosis must be differentiated from that of other disorders that are similar to ASD. When psychologists or
psychiatrists make these decisions, it is called a differential diagnosis.
Co-morbid Diagnoses. Some disorders may occur simultaneously with ASD. In

these cases, students should appropriately be diagnosed with an ASD and be diagnosed with an additional disorder. When psychologists or psychiatrists make these
decisions, the additional diagnosis is called a co-morbid condition.
To confuse the matter further, some disorders may appear as a differential diagnosis for one child and as a co-morbid condition in another child. For example, consider a
young boy who has the following challenges at school:
Has social problems with other students
Seems to violate social rules with adults, like talking when the teacher is talking
Tends to look away from tasks that are presented to him
Throws tantrums when things do not seem to go his way
Misunderstands comments made by others
Cannot seem to sit still
Does this child have an ASD? Attention Deficit Disorder? Both? Obtaining a clear
and comprehensive evaluation from a qualified professional is the first step to clarifying
whether a child has an ASD or requires a different or additional diagnosis.
School professionals often play an instrumental role in referring a child or adolescent
whose correct diagnosis may have otherwise been missed by medical professionals or
family members. We hope this information helps you make referrals for some of your
students whose pattern of symptoms may be very complicated. After all, the sooner
they get the proper diagnosis and support they need, the more quickly and fully they
will achieve their potential.
Whenever a psychiatric or psychological disorder is suspected, it is important that a qualified

diagnostician conduct a comprehensive assessment and render treatment recommendations.
Frequently Occurring Diagnoses & Conditions

Anxiety and Depression
Mood dysregulation and anxiety symptoms can be easily missed in children with
ASD. On the other hand, a high-functioning teenager with undiagnosed ASD may
only come to someones attention specifically because of symptoms of depression
or anxiety.
Consider the following diagnostic challenges related to depression:

A teenager who is increasingly isolated, avoiding his peers more often or in different ways, and spending excessive amounts of time focused on a specific topic
of interest may have symptoms of depression secondary to an ASD diagnosis.
In teens with ASD, classic symptoms of depression may sometimes be masked.
Their ability to effectively communicate their emotional states may be limited.
Therefore, mental health professionals may have to do some sleuthing to determine if behaviors observed are congruent with ASD in isolation, or ASD paired with
a mood disorder. School professionals who have the opportunity to observe the
student in a wide variety of circumstances may provide the information essential to
making the correct diagnosis.
Anxiety symptoms can also be misleading. Consider the following diagnostic

challenges:
A child who is anxious about speaking in public may not only have a common
phobia (e.g., public speaking), but may also be masking a tic disorder (a common
symptom in ASD) that could be exacerbated by the activity.
For many students, school refusal is linked with anxiety-based disorders. However, the student with ASD may also avoid school because the school day is
too strenuous due to the high demand for social interaction and need to control
stereotypic or self-stimulatory behavior (e.g., some children develop enough
self-control to stop themselves from engaging in repetitive motor mannerisms at
school but are exhausted at the end of the day as a result).
Anxiety levels should be regularly evaluated for students with ASD to make certain they are receiving appropriate services.
Attention Deficit Hyperactivity Disorder

Children between the ages of 5-7 (or even younger) can be diagnosed with
Attention Deficit Hyperactivity Disorder (ADHD). This disorder affects a childs ability
to remain focused and to attend to tasks at hand. As noted previously, some children with ADHD may also be impulsive and explosive, and have extreme difficulties
remaining seated or following simple classroom rules.
Consider the following diagnostic challenges:

Children with ASD may have difficulty with attention and concentration. They may
experience the same behavioral challenges as a child with ADHD. However, the
reason for the behavior is different. A child with ADHD may lose focus because
he is thinking about recess. In contrast, a child with ASD may lose focus because
he is fixating on the color of the teachers sweater or watching the fan rotate. In
addition, students with ASD may not be able to concentrate because instructions
are too complicated given their communication difficulties.
A child with ADHD may engage in problem behaviors due to pent-up energy. In
contrast, a child with ASD may act out behaviorally due to a sensory interest or
repetitive motor or vocal tic symptom. The same behaviors occur in both children, but there may be very different causes or triggers.
Carefully identifying the function or purpose of a behavior is often critical. The
function of the behavior may influence both the diagnosis that is rendered and the
treatment that is recommended.
Obsessive-Compulsive Disorder
Children with ASD often display stereotypic or self-stimulatory behaviors. That is,
they ritualistically repeat the same set of behaviors. Based on simple observation, it
is often difficult to distinguish the compulsive behavior of an individual with obsessive-compulsive disorder (OCD) and the self-stimulatory behavior of an individual
with ASD.
Consider the following diagnostic challenges:

Children with ASD and children with OCD might line up their toys, categorize
things, insist on sameness in their routines or rituals, or have strange rules that
they create to govern their actions with others. However, the children with OCD
often have anxiety-based thinking that is intimately linked to their behaviors. For
instance, a child with OCD may feel compelled to line up all of her shoes facing north and according to color. Usually, there is a thought associated with the
behavior, such as I need to line my shoes up, so the house wont burn down
while I am at school today. In contrast, the child with ASD might identify a
preference for sameness or, more likely, will be incapable of articulating why he
engages in these behaviors.
Repetitive hand-washing may be a self-stimulatory behavior for a student on the
autism spectrum or it may be associated with intrusive fears of contamination
and disease for the child with OCD.
It may be particularly difficult to make the distinction between compulsive and
self-stimulatory behaviors with children who lack strong communication skills.
Making the appropriate differential diagnosis may be based on the childs ability to
express whether or not intrusive thoughts and fears are present. Also, children with
OCD often state that they wish they did not perform the compulsions. The appropriateness of specific medical treatments is clearly tied to the correct diagnosis.
Psychotic Disorders
Some children with ASD are mislabeled as psychotic.
Consider the following diagnostic

challenges:
A student with ASD may talk to himself and mumble under his breath
in the classroom. When the teacher
asks about this behavior, he states,
I was just talking to my friends. It
is clear to the front-line interventionists that this child was not speaking
to any friends in the classroom!
However, in the childs mind, he was
responding to actual conversations
that had occurred around him in the
lunch room earlier that day. Its just
that he does not understand the
reciprocal nature of communication
and social interaction. In his mind,
he was talking to friends in the
classroom.
Asking children who are on the
spectrum about hearing voices
or seeing strange things is
likely to elicit some unusual and
misleading responses as well. For
instance, a student with ASD may
state she is always hearing voices
of people who are not in the room

with her. However, she is referring
to people downstairs, down the hall,
or outsidenot in her head. She
is responding quite literally to the
question that has been asked.
Children with ASD may repeat
fantasy-based activities that they
have seen on television, or in video
games or movies. They may or may
not realize that what they are acting out is make-believe or pretend
play. For instance, a boy with ASD
may perfectly replicate every move
made by Spiderman. If asked, he
may insist that he is Spiderman
and may have a tantrum when you
challenge this statement. He is not
truly psychotic, but he may benefit
from some guidance in reality testingmostly for his own safety and
the safety of others.
Significant differences exist in the
treatment of psychotic disorders and
ASD. While these conditions may
be co-morbid, you should consult a
qualified professional with sufficient
experience with both disorders if a
psychotic disorder is suspected.
Bipolar Disorder and

Oppositional Defiant
Disorder
The most confusing symptom we probably see in children with ASD is linked to
behavioral outbursts. Many professionals
who are not familiar with ASD assume a
childs behavior is due to a mood disorder
such as bipolar disorder, or a behaviorally
driven diagnosis such as oppositional defiant
disorder (ODD). The true cause of the behavior can be quite different.
Consider the following diagnostic

challenges:
Children with bipolar disorder can be
explosive, impulsive, and highly aggressive. Their symptoms are often cyclical
and follow a pattern over time that can be
tracked and monitored. However, most
people do not regularly monitor these
behaviors in a way that makes the pattern
readily apparent.
There is not typically an environmental
stressor that is the primary trigger for the
explosive, impulsive, and highly aggressive behavior for children with bipolar
disorder. These behaviors are ruled by
fluctuations of the chemicals in their
brains that lead to (sometimes highly
rapid) changes in their overall behavior.
Although students with ASD may have
these same symptoms, their problems are typically tied to environmental
stressors. It may not be readily apparent, however, what that environmental

stressor might be (e.g., days in which
math and music both appear in the afternoon may not be a pattern most people
would easily recognize!).
Children with ODD often act out for very
specific reasons. They are often inadvertently taught to respond to limit-setting in
a negative manner. When positive behavioral supports are provided, they are often
able to restructure their responses in a
positive and motivated way. In contrast,
the child on the autism spectrum may act
out because the noise in the next room is
highly distressing even though it does not
bother any of the other students in the
classroom. He may rock back and forth,
cover his ears in response to the noise,
and hit the girl next to him who tries to
console him. He is unlikely to calm down
until the sensory stressor is removed, or
until he has become accustomed to the
sound (this is not likely to happen quickly).
The behaviors may look the same for
the student with ASD, the child with ODD,
or the individual with bipolar disorder (e.g.,
Johnny hits Susie in the classroom), but the
underlying reasons for the behavior are much
different (i.e., chemical dysfunction, learned
behavior, sensory-driven behavior, or rulebased behaviors). Determining what caused
the behavior in the first place often leads to
an accurate diagnosis.
Final Considerations
Being aware of ASD diagnoses and their myriad presentations will be an
important step in helping children with ASD in the school setting. Working
closely with other educators, treatment providers, and diagnosticians in the
field will help close the gaps between identification, intervention, and the best
possible outcome for the child.
Even when outside professionals are involved, school personnel remain the front
line in helping students with ASD reach their potential. This is most likely to occur
when the needs of students with complicated school behavior and psychiatric histories
are examined within their proper context.
Once a proper diagnosis is secured, treatment selection begins. It typically begins
with identification of treatments that have been shown to be effective based on wellcontrolled research. Chapter 2 includes a discussion of research-supported treatments
for ASD.
Recommended Readings}
Autism Specific:
Other Disorders:
Attwood, T. (2007). The complete guide to

Aspergers syndrome. Philadelphia, PA:
Jessica Kingsley Publishers.
Barkley, R. A. (2000). Taking charge of ADHD: The

complete authoritative guide for parents.
New York, NY: Guilford Press.
Baron, M. G., Groden, J., Groden, G., & Lipsitt, L.

P. (2006). Stress and coping in autism. New
York, NY: Oxford University Press, Inc.
Geller, B., & DelBello, M. P. (2003). Bipolar disorder in childhood and early adolescence.
New York, NY: Guilford Press.
Bolick, T. (2001). Aspergers syndrome and

adolescence: Helping preteens and teens get
ready for the real world. Gloucester, MA: Fair
Winds Press.
Penzel, F. (2000). Obsessive-compulsive disorders:

A complete guide to getting well and staying well. New York, NY: Oxford University
Press, Inc.
Lord, C., & McGee, J. P. National Research

Council, Committee on Educational
Interventions for Children with Autism.
(2001). Educating children with autism.
Washington, DC: National Academy Press.
OBrien, M., & Daggett, J. (2006). Beyond the
autism diagnosis: A professionals guide
to helping families. Baltimore, MD: Brooks
Publishing.
Ozonoff, S., Dawson, G., & McPartland, J. (2002).
A parents guide to Aspergers syndrome
and high functioning autism. New York, NY:
Guilford Press.
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and statistical manual of mental disorders (4th
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Kabot, S., Masi, W., & Segal, M. (2003). Advances in

the diagnosis and treatment of autism spectrum
disorders. Professional Psychology: Research and
Practice, 34, 26-33.
American Psychiatric Association (2000). Diagnostic

and statistical manual of mental disorders (4th
ed., TR). Washington DC: American Psychological
Association.
Klinger, L. G., Dawson, G., & Renner, P. (2003). Autistic

disorder. In E. J. Mash & R. A. Barkey (Eds.), Child
psychopathology (2nd ed., pp. 409-454). New
York, NY: Guilford Press.
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Fombonne, E. (2003). Epidemiological surveys of autism
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Early detection of core deficits in autism. Mental
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Walker, D. R., Thompson, A., Zwaigenbaum, L.,
Goldberg, J., Bryon, S. E., & Mahoney, W. J.
(2004). Specifying PDD-NOS: A comparison of
PDD-NOS, Aspergers syndrome and autism.
Journal of American Academy of Child and
Adolescent Psychiatry, 43, 172-180.
Wing, L., & Gould, J. (1979). Severe impairments of
social interaction and associated abnormalities in
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of Autism and Developmental Disorders, 9, 11-29.
Wong, V., Hui, L., & Lee, W. (2004). A modified screening
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166-176.
Research Findings of the

Our understanding of Autism Spectrum Disorders (ASD) continues to evolve,
bringing refinements in both diagnosis and treatment. More than 50 years of
research have increased our knowledge of this complex developmental disability and led to a vast array of treatment options.
The need to evaluate and select from this long list of treatment options can be
daunting for all of usparents, educators, and health professionals. The good news is
that information is available to help us focus on those interventions with evidence of
effectiveness.
Consider the following:

We expect our health professionals to recommend medications or medical interventions that meet a high standard of evidence based on sufficient research findings.
We should have equally high expectations for our educational and behavioral specialists who serve children with autism.
The lifetime costs associated with ASD are high ($3.2 million per individual (Ganz,
2007). We can reduce these costs by choosing and providing treatments that have
evidence of effectiveness (e.g., Behavioral Package, Modeling, Peer Training Package, Schedules, etc.).
It is not possible to be experts in all available treatments. We can, however, focus
our attention and resources on those treatments which research has shown to be
effective.
In 2009, the National Autism Center completed a comprehensive, multi-year effort

called the National Standards Project. Its goal was to identify the level of research
support available for interventions for children and adolescents with ASD. The results
of this effort are available in the Findings and Conclusions of the National Standards
Project report which we have included in the appendix of this manual. We recommend
that all front-line interventionists take the time to read these findings.
Here are a few important points from the report:

A thorough and systematic review of the treatment literature is necessary to determine whether a treatment is effective.
There are 11 Established Treatments that have been thoroughly researched and
have sufficient evidence for us to confidently state that they are effective.
There are 22 Emerging Treatments that have some evidence of effectiveness, but
not enough for us to be confident that they are truly effective.
There are Unestablished Treatments for which there is no sound evidence of
effectiveness.
This chapter focuses on the 11 Established Treatments identified in the Findings
and Conclusions report. Our goal is to familiarize you with these treatments and give
you a place to beginor continueyour exploration of available resources. Once you
have decided which of these Established Treatments will be the best option(s) for your
students and school, we recommend that you develop a collaborative and carefully
planned strategy in order to build your schools capacity to implement these interventions with a high degree of accuracy (see Chapter 5).
Established Treatments
In the following pages, we provide a detailed definition and description for
each of the 11 Established Treatments, or interventions, identified in the
Findings and Conclusions report.
You may already be familiar with some of these options. Many volumes have been
published on each of these interventions; we encourage you to learn more about those
that might be most useful to you in your work. At the end of the chapter you will find a
list of various sources that provide more in-depth discussion of these treatments.
The 11 Established Treatments are:

Antecedent Package
Behavioral Package
Comprehensive Behavioral Treatment for Young Children
Joint Attention Intervention
Modeling
Naturalistic Teaching Strategies
Peer Training Package
Pivotal Response Treatment
Schedules
Self-management
Story-based Intervention Package
Antecedent Package
Antecedent interventions include a group
of treatments designed to modify the environment before a target behavior occurs. These
treatments have been shown to effectively
reduce problem behavior and improve a broad
range of developmentally appropriate skills.
By concentrating on how we can modify the
environment ahead of time, we can support a
students learning and decrease the likelihood
of problem behaviors.
Facts about Antecedent Package

treatments:
They have been shown to be effective with
students aged 3-18 years
They are associated with favorable outcomes for individuals diagnosed with
autism
They are effective with a wide range of
target skills and behaviors, including:
Communication skills
Interpersonal (or social) skills
Learning readiness
Personal responsibility (e.g., daily living
skills)
Play skills
Self-regulation
Problem behaviors
Sensory and emotional regulation
Most often, Antecedent Package interventions involve observing the student in
the setting where problem behaviors occur,

then determining which of many possible
environmental changes are appropriate. As
you decide which environmental modifications to make, it is helpful to consult with an
experienced behavior specialist about how to
identify the events that lead to the behavior
of concern (e.g., off-task behavior, self-injury,
problems keeping hands and feet to self,
etc.).
Treatments included in the Antecedent
Package are often cost-effective and require
minimal time. As you consult with a qualified
behavior specialist, you can work collaboratively to develop simple-to-use strategies that
are feasible in most settings.
Antecedent modification of staff, materials, tasks, and motivating variables should be
considered alone or in conjunction with other
treatments. Antecedent modifications are
often made in combination with treatments in
the category of Behavioral Package, another
Established Treatment discussed below.
There are many treatments that fall into
the category of Antecedent Package, including: choice; behavior chain interruption;
cueing and prompting; stimuli manipulation;
priming; high probability sequencing; noncontingent reinforcement; incorporating echolalia
and an individuals obsessive behaviors;
time delay; errorless learning; satiation; adult
presence; contriving motivational operations;
intertrial interval; and habit reversal.
It is beyond the scope of this manual to familiarize you with all of these treatments.
Experienced specialists, as mentioned above, can provide invaluable information, feedback, and support in the use of antecedent (and other) strategies. We provide some
examples below to help highlight the importance of Antecedent Package interventions.
Consider the following examples of challenges you might encounter, along

with their possible treatments:
Example 1: Cathy is a student in your classroom who often has problems with
talking out around 2 p.m. The behavior specialist in your school collects data and
notices a relationship between food intake and Cathys excessive talking out. He
finds that Cathy tends to talk out in a disruptive way on days when she eats a small
lunch. The behavior specialist consults with you about the possibility of giving Cathy
a brief snack break at 1:30 p.m. Cathys parents are happy to provide a daily snack if
it helps her stay focused in the afternoon. The behavior specialist reminds you that it
is important to give the snack before the problem behavior starts to occurotherwise Cathy may learn to talk out more in order to get a snack!
Example 2:
Your goal is to help your student, David, learn to ask to open the door
(e.g., you want David to say open door). You know you will need to prompt him
initially, but you want him to learn to initiate independently in naturally occurring situations. You decide to use the time delay prompt described below.
David receives weekly half-hour sessions with the occupational therapist. You
know that he is motivated to go and responds positively to the activities included
in the sessions. Therefore, when the occupational therapist comes to pick David
up, she puts his hand on the door handle and looks expectantly at him. She then
says open and encourages David to imitate her. When he does, she opens the
door. Gradually, the occupational therapist will wait for a few seconds without saying open, and David will learn to say it himself. This same strategy is used by the
speech-language pathologist and the paraprofessionals when it is time for David to
leave the classroom.
Example 3:
As you know, echolalia (repeating back what someone else says) can
interfere with instruction and learning. But school professionals have identified creative ways to incorporate echolalia into treatment for students with ASD.
Consider the case in which one teacher incorporates echolalia into an activity
designed to increase receptive labeling (correctly identifying objects or pictures
when told the name of the item). The teacher states the name of an object, and
her student echoes the label. The teacher then places two objects (one of them the
labeled object) in the students hands. She holds out her own hand, and re-states
the label. The student successfully responds by giving the correct object to the
teacher. The study shows that this sequence of incorporating echolalia is effective in
increasing student accuracy of receptive labels (Charlop, 1983).
Example 4:
Planned modification of the environment is also effective in decreasing

challenging behaviors. Lets consider the case of a 19-year-old student with autism
who had frequent problems with rumination (bringing up partially digested food,
chewing, and re-swallowing the material). Assessments showed that when the
young man consumed liquids during meals, he was more likely to ruminate. When
the staff rescheduled his consumption of liquids to a time other than mealtime, his
rumination decreased (Heering, Wilder, & Ladd, 2003).
Behavioral Package
Treatments included in the Behavioral Package category are based on behavior
principles. These treatments begin with an evaluation of what happens in the environment before and after a behavior you are targeting. Then, using the data that youve
collected, you can begin to modify the environment accordingly. As with all treatments,
your goal is to maximize a students success.
Focusing on their areas of expertise, school professionals might use Behavioral
Package treatments to target behaviors that appear on a students Individualized
Educational Plan (IEP). A speech-language pathologist might target speech, for
example; a preschool teacher might target play; a high school teacher might target
homework completion; and a psychologist might target problem behaviors.
Treatments in the Behavioral Package category are often based on both antecedents and consequences. We have already discussed a few antecedents that can be
modified with the Antecedent Package. The key difference in the Behavioral Package
category is that changing consequences to improve performance is always an essential
component of the treatment.
There are four fundamental consequences that explain most behavior:

1. When a positive consequence happens after a behavior occurs, that behavior is
very likely to re-occur in the future. For example, Jane says cookie and her mom
gives her a cookie. In the future, when Jane wants a cookie, she is highly likely
to say cookie. Similarly, if Jane wants a cookie and throws a tantrum (e.g., pulls
her mothers arm and screams), and her mother gives her a cookie, the likelihood
is high that Jane will pull her mothers arm and scream the next time she wants a
cookie.
2. When a negative consequence happens after a behavior occurs, that behavior is
very likely to decrease. Lets say Jane wants a cookie. Jane screams and cries and
her mother says, No cookies for you. Her mother doesnt give in, and Jane doesnt
get a cookie. There is likely to be less crying and screaming in the future when Jane
wants a cookie.
3. When a positive consequence is removed after a behavior occurs, that behavior
is less likely to occur again. For example, if Jane is playing with her dog and the
dog eats her cookie, Jane will most likely decrease her future interaction with the
dogespecially when she has a cookie in her hand!
4. When a negative consequence is removed after a behavior occurs, that behavior is
more likely to occur again in future. For example, lets say Jane hates broccoli. She
begins to scream and cry when her father serves her broccoli. He decides it is not
worth all the fuss and takes the broccoli away. As a result, Janes screaming and
crying is likely to re-occur when she is served broccoli.
Before the experienced behavior specialist proceeds to intervention, she knows it

is important to identify the function of the
childs behavior. She may observe, or ask the
caregiver to observe, the consequences that
follow the problem behavior. Consider George
as an example. When George displays problem behavior in the classroom, his teacher
frequently takes his work away. When she
does so, Georges problem behavior ends. A
reasonable hypothesis is that the function of
Pervasive Development Disorder-Not Otherwise Specified (PDD-NOS)

Are effective with a wide range of target
skills and behaviors, including:
Academic skills
Interpersonal (or social) skills
Learning readiness
Personal responsibility (e.g., daily living
skills)
Georges behavior is to escape or avoid the
Play skills
work.
Self-regulation
Even though it seems counter-intuitive

to take work away when a student is demonstrating problem behavior, this scene
plays out quite frequently in classrooms
everywhere. How often do students avoid or
escape their work because they have been
sent to time out? In this case it is important
to test the hypothesis that Georges behavior is continuing because it allows him to
escape hard work. This can be done through
Problem behaviors
Restricted, repetitive, nonfunctional patterns of behavior, interest, or activity
There are many treatments that fall into
the category of Behavioral Package, including:
behavioral sleep package; behavioral toilet
training/dry bed training; chaining; contingency contracting; contingency mapping;
delayed contingencies; differential reinforce-
a functional analysis. Once the hypothesis is
ment strategies; discrete trial teaching;
confirmed, functional communication train-
functional communication training; generaliza-
ing (a Behavioral Package treatment strategy)
tion training; mand training; noncontingent
may be appropriate.
escape with instructional fading; progressive
Behavioral Package treatments:

Have been shown to be effective with
individuals aged 0-21 years
Are associated with favorable outcomes
for individuals diagnosed with autism and
relaxation; reinforcement; scheduled awakenings; shaping; stimulus-stimulus pairing with

reinforcement; successive approximation;
task analysis; and token economy. These
treatments involve a complex combination of
behavioral procedures.
Consider the following examples of successful interventions using

Behavioral Package strategies:
Example 1: In our earlier example, Cathy started talking out around 2 p.m. on days
when she did not eat enough lunch. The behavior specialist identified an antecedent intervention. He might have also implemented a treatment from the Behavioral
Package category. For instance, Cathy could be taught to identify when she is getting hungry, and then to request food instead of engaging in disruptive behaviors.
She would then be given food when she requests it.
Example 2:
An instructor is teaching a young boy to request preferred items. She

asks the boy, What do you want? When the boy doesnt respond, the instructor models the correct response (bubbles). If the boy still does not respond,
the instructor models the initial phoneme of the response (/bu/). Over time, the
boys ability to accurately make requests using the whole word increases (Bourrett,
Vollmer, & Rapp, 2004).
The key at the start of this kind of training (known as mand training) is to choose
a highly preferred item, so that the child will be motivated to gain access to that
item. If a student is highly motivated by juice, for example, teaching him to request
juice will likely produce more effective results than teaching him to ask for
water.
Example 3:
Behavioral Package interventions may have multiple components. For

example, students with ASD often benefit from interventions designed to increase
their independence. But independent responding does not always result from a
simple reinforcement schedule (although it is nice when it does!).
Pelios, MacDuff, and Axelrod (2003) used a multi-component treatment to target
independent academic work skills of children with ASD. The treatment package
included many different components including: reinforcement (contingent or
delayed) for correct responding; fading teacher presence and prompts; response
cost for incorrect responding; and unpredictable pattern of supervision. Following
the intervention, students who were previously dependent on high levels of teacher
supervision and prompts were able to complete these tasks with minimal teacher
supervision.
Comprehensive
Behavioral Treatment
for Young Children
Human beings learn at an astounding
rate, especially during our early years. This is
why early intervention is so important! When
younger children with ASD receive effective
early intervention, they are more likely to
reach their potential across a range of skills
(e.g., communication, social, pre-academic/
academic, etc.). Comprehensive Behavioral
Treatment for Young Children (CBTYC) programs are designed to meet this need.
The treatment programs represented

in the CBTYC category have various
defining features, including:
Intense service delivery based on applied
behavior analysis (ABA), and measurement
to assess the effectiveness of the program
These comprehensive programs typically

combine many of the behavioral interventions identified in this manual. CBTYC
include strategies associated with each
of the following treatments: Antecedent
Package, Behavioral Package, Joint Attention
Intervention, Modeling, Naturalistic Teaching
Strategies, Peer Training Package, Schedules,
and Self-management.
CBTYC has been shown:

To be effective with children aged 0-9
years (the age group to which it is usually
applied)
To be associated with favorable outcomes
for individuals diagnosed with autism and
PDD-NOS
To be effective with a broad range of target
skills and behaviors, including:
Higher cognitive functions
Provision of services in various settings,

(e.g., home, community, inclusive classrooms, and self-contained classrooms)
Interpersonal skills
Rich student-to-teacher ratio
Placement
Motor skills
Personal responsibility
Targeting the defining symptoms of ASD
Play skills
Using applied behavior analytic strategies

(e.g., discrete trial teaching, incidental
teaching, errorless learning, behavioral
momentum, and shaping)
Problem behaviors
Written guidance through treatment manuals and other materials
General symptoms associated with

ASD
The intensive nature of this ABA-based
instruction is achieved through a rich studentto-teacher ratio. That is, there are very few
students for every teacher (often there is a 1:1 ratio). Such a ratio is important to
ensure the teacher is able to attend to the student completely, individualize the instruction, and provide immediate reinforcement. Intensity is also addressed by providing
many hours of services weekly and extending service delivery over a long period of
time. Often, these treatment programs provide services to children for two or three
years.
There are a number of treatment programs that provide CBTYC. In the most wellknown program, Lovaas (1987) first evaluated the effectiveness of CBTYC in a study
of 19 children with ASD. They received services for 40 hours per week over a long
period of time (2-3 years). These children showed significant gains in IQ scores. Most
important was the fact that the treatment effects were maintained over time. By comparison, children who received 10 hours of special education per week did not show
similar gains.
Other researchers questioned whether Lovaas (1987) CBTYC was successful only
because of the amount of time spent in instruction. So, they compared three different
treatments: {a} 25-40 hours of CBTYC; {b} 15 hours of a traditional preschool program;
and {c} 30 hours of eclectic intervention. In the end, treatment effectiveness was found
to be related to the type of treatment. CBTYC was effectiveit was not merely the
length of time spent in treatment that led to gains for children receiving CBTYC services (Howard, Sparkman, Cohen, Green, & Stainslaw, 2005). Many additional studies
have confirmed CBTYC is effective with many children on the autism spectrum.
Due to the complexity of CBTYC, it is difficult to develop an example that reflects
all aspects of treatment. Most children received a minimum of 25 hours of services
per week. Instruction varies depending on their communication, cognitive, social, and
adaptive skills as well as problem behaviors that interfere with skill acquisition and
success across important environments in the childs life. A student who first enters a
CBTYC program may spend a large part of the day in discrete trial teaching, whereas a
student further along in treatment may spend a good deal of time generalizing skills to
new situations, materials, or people. CBTYC programs can be center-based or homebased (with some community activities). Center-based programs may involve a great
deal of peer involvement or may focus almost exclusively on the student with ASD.
Irrespective of these differences, the applied behavior analytic techniques produce
important gains across a broad range of critical life skills.

Joint attention is a widely used term in the field of ASD. It refers to the behavior of
two individuals focusing simultaneously on an object or activity and each other. The
sharing of an activity is a fundamental skill in communication and social behavior, but
it is not a skill that children with ASD automatically develop. Failure to develop joint
attention skills may be one of the earliest indicators parents notice when they get the
feeling that something is not quite right.
Here are several examples of Joint Attention interactions:

A childs eye gaze follows the adults eye gaze (i.e., the parent looks at some object
or event and the child follows the parents shift in eye gaze).
A child prompts someone to look at an item. Joint attention also occurs when
someone prompts a child to look at an item and the child responds to this bid.
A child shows an object to another person, or responds when someone else shows
the child an object.
A child points to an object, or responds when an adult points to an object.
A child and adult watch an activity together and look to the response of the other
person.
Very often, joint attention is taught in a discrete trial teaching format. You begin by
deciding which joint attention skill to target. In other words, it is important to clarify if
the goal is to teach the child to initiate a joint attention interaction, or to respond to a
bid from others.
Here is a sample joint attention interaction designed to teach a young child to
respond by looking at an object when you point to it. Because you want to motivate
the child, you begin by identifying something you know she wants to look at. Because
you have observed her, you know that she is drawn to objects that light up. Therefore,
you select a number of toys that light up. You decide where to teach this skill (e.g., the
free play area, a table that has been set up to teach this skill, or an area of the floor that
is near other children but wont be distracting to your young student). Placing your hand
close to the childs face, you point at a light-up toy. When she sees your finger, you
guide her to look at the toy. You then push the button so the toy lights up. You are now
ready to repeat the exercise.
Along with the steps described above, teachers can use strategies such as choice,
task interspersal, modeling, and reinforcement when teaching children to demonstrate
joint attention.
Joint Attention treatments:

Have been shown to be effective for children aged 0-5 years (the age group to
which it is usually applied)
Have shown favorable outcomes for children diagnosed with autism and PDD-NOS
Have been shown to increase communication and interpersonal skills
Consider the following cases of successful interventions using Joint

Attention strategies:
Example 1: As noted in Chapter 1, using gestures is an early skill that many
children use to communicate their interests to others. In one study, two other
Established Treatments (discrete trial training and Pivotal Response Training) were
combined to teach protodeclarative pointing (pointing with the intention of showing,
not requesting) to children with ASD (Whalen & Schreibman, 2003). These strategies teach children essential joint attention skills.
Example 2:
Time-delay prompts can be used to supplement other behavioral strategies for improving joint attention. For example, three children with ASD (Martin
& Harris, 2006) were taught to respond to increasingly difficult joint attention bids
from adults. Eventually, the children learned to respond when an adult got their
attention and then looked at an object of interest (i.e., no gestures or comments
were required).
Example 3:
Children benefit from coordinated efforts across home and school

environments (more on this subject in Chapter 4). Home environments provide additional and rich opportunities to generalize skills learned at school, to practice new
skills, and to increase the number of positive interactions with family members. For
all these reasons, school systems may want to provide joint attention training for
parents. Parents can develop competence in using behavioral strategies to teach
joint attention skills to their children with ASD. Joint attention responses can be
developed over a short period of time, and the majority of children are able to generalize the skill to other settings (Rocha, Schreibman, & Stahmer, 2007).
Modeling
The best and clearest way to teach someone what to do is to show him what to do.
When we are children, we learn a great deal
from observing the modeling provided by
our parents, siblings, peers, and teachers.
Even as adults, we continue to benefit from
modeling. Take the example of trying to learn
a new exercise routine. Reading about it or
having someone explain it will not give us a
complete understanding of the actual routine.
However, if someone spends a few minutes
showing us exactly how that routine is performed, we benefit tremendously.
Modeling has been shown:

To be effective for children aged 3-18 years
To have favorable outcomes for children
with autism, Aspergers Syndrome, and
PDD-NOS
To be effective with target skills and behaviors, including:
Higher cognitive functioning
Personal responsibility
Play skills
Problem behaviors
Modeling may be provided in several ways.
Live modeling occurs when a person demonstrates the target behavior in the presence of
the student with ASD. The model may be an
adult or a peer. In contrast, video modeling

occurs when the individual demonstrating the
target behavior has been pre-recorded.
When videos are used to model the target
behavior, the student with ASD may serve
as the model (i.e., self-modeling) or another
person may be selected as an effective model
for the targeted behavior. Self-modeling may
require significant editing of the video by
the educator in order to make the student
appear to successfully perform the task
independently.
Video allows for point-of-view modeling (i.e., seeing the target behavior from
the perspective of the person performing
the behavior). Point-of-view modeling often
involves videotaping someones hands performing a task.
There are some advantages in the use
of video modeling over live modeling. A live
model may not always be available. With a live
model, you must also ensure that steps are
modeled consistently (i.e., in the same manner, during every session).
Another benefit of video modeling is that it
can be cost- and time-effective. For example,
the same video clip can be used by multiple
children and at multiple times of day. Also,
teaching sessions can be as quick and simple
as turning on a switch! Of course, it is not this
easy with all students. Some children may
need prompting to pay attention to the video.
Educators may also need to stop the video
and point out the salient features.
Anyone with the necessary equipment (video camera, TV, and VCR or DVD player)
can use video modeling as a treatment. The first step is to create the video clip.
Although making video clips is not difficult, you should be aware of several elements
that make an effective clip, such as the angle of the shot, voice quality, clarity of
materials, and duration of the video. Finally, be aware that technical difficulties such as
equipment malfunctions can be challenging during the treatment stage.
Consider these examples of Modeling:

Example 1: If a speech-language pathologist needs to target conversational skills
for a student, he could design a treatment using video modeling. The video might
show adults having conversations (i.e., how to initiate and maintain conversation by asking and answering questions). The next step is to decide how often the
student should watch the video. Typically, the video is shown to the student immediately before the student practices holding the same conversation. Keep in mind
that students should be reinforced for acceptable deviations from the videotaped
conversation.
Example 2:
In some cases, live modeling is a better option. Consider the case of

Steve, a 16-year-old student for whom you have used video modeling in the past.
While video modeling works well with many students, Steve seems to have a
hard time performing the modeled task unless everything in the classroom setting
appears exactly the way it does in the video. Therefore, you decide that the variability that may naturally occur with live modeling may be better for Steve. You train two
peers to model the target behavior (in this case, how to make plans to meet a friend
at lunch). Although you used the exact same teaching procedure with both peers,
you notice there is some natural variation in the way they demonstrate the target
behavior. It may take a bit longer for Steve to pick up how to perform the task with
this variation, but he seems to respond better in the real world when he needs to
perform this task.

When we learn to drive, we start in a parking lot. But the point of acquiring that skill
is to be able to drive in our neighborhood, on city roads, and ultimately on major highways. Similarly, it is important for a child with ASD to perform skills in all environments
where they naturally occur.
Children with ASD face challenges not only in acquisition of skills, but also in generalization of those skills. Generalization refers to the ability to perform any acquired skill
across different stimuli and settings, and with different people. Teaching a child to tie
his shoelaces in a classroom is useful only if the child can then tie his shoelaces in the
playground, cafeteria, car, home, etc.
Generalization can be achieved in two ways. The first is to teach a skill in a controlled environment and then gradually vary the materials and location (in and out of
classroom), and even change the instructor. The second way to achieve generalization
is to embed it into teaching from the beginning, using naturalistic procedures. As the
name suggests, these procedures take advantage of naturally occurring events in a
students day to teach and maintain new skills.
Many strategies for enhancing generalizations have been described in the research
literature (Stokes & Baer, 1977).
A few of the most important principles are outlined here.

The first principle instructs us to use direct and natural consequences. The natural
consequence that directly relates to our actions is what motivates us in everyday
life. For example, the consequence for learning to drive is the freedom and independence of driving, and of being able to move from one location to another as needed.
It also enables us to attain other things that may be rewarding to us: the opportunity to see a movie, purchase clothing or other desired items, visit a park, etc.
When you were 16 years old, how motivated would you be to get your drivers
license if your only reward was to get a 5% discount at the local grocery store
(instead of earning the right to drive where you wanted and when you wanted)? Not
at all, were sure! To be the most meaningful, reinforcers should be directly related
to the skill that is being developed (this is known as a direct response-reinforcer
relationship). In addition, the reinforcer should be naturally available in the environment (e.g., you do not need to contrive special occasions to allow a teenager to
drivethey are naturally available).
The second principle involves the old saying, variety is the spice of life. In this
case, we would more aptly say, variety can lead to meaningful improvements.
Although we doubt this phrase will catch on, it is an important consideration for
Naturalistic Teaching Strategies (NTS). When teaching students new skills, you
should use a variety of different materials and teach skills in a variety of settings
and/or situations. For example, if your goal is to teach a preschooler his colors, you
might use different colored crayons, cars, mats upon which to sit, or any other
appropriate materials in the classroom. Colors can also be taught on the playground,
in the hallways, in the home, or in the community. When followed consistently, this
principle is likely to increase generalization of the targeted skill.
The third principle is called programming common stimuli. This means that the
materials you use to teach new concepts or skills are likely to be available in a
variety of settings (home, school, and community). For example, you might want to
teach a young student to identify items that fall into the category things you might
play with using dolls, blocks, and cars that are available at home and at school.
Generalization of skills relevant to life contexts is the foundation of NTS. There are a
number of different intervention strategies that fall into this category. These strategies
have several features in common. For example, Naturalistic Teaching Strategies involve
following the interest of the child when structuring teaching interactions. By following
the childs interests:
You are more likely to identify direct and natural reinforcers. This often requires
careful observation and planning. You will need to set aside any preconceived
notions about what might be interesting to the student and decide based on her
actual contact with and response to different classroom materials.
You will capitalize on the students motivation if you follow his interest. A lack of
motivation is one of the great challenges most educators face when teaching
students with ASD. Close observation of the students actual behavior is critical
to making the right decisions about reinforcers.
You will need to develop loosely structured teaching sessions that vary based
on the students interests on a given day.
If your goal is to increase your students
ability to request toys, you may need to
shift your plans from work on requesting
different colored blocks to requesting
popular action heroes based on a recent
movie. If the childs interest shifts, your
teaching shifts along with itbut you
keep your primary goal of teaching (in
this case, requesting) in mind.
Different names have been given to the
treatment strategies included in the NTS
category. These include focused stimulation,
incidental teaching, milieu teaching, embedded
teaching, and responsive education and prelinguistic milieu teaching.
Naturalistic Teaching Strategies:

Have been shown to be effective for children aged 0-9 years
Have produced favorable outcomes for children with autism and PDD-NOS
Have been shown to be effective with target skills and behaviors, including:
Play skills
Consider the following examples

of successful interventions using
Naturalistic Teaching Strategies:
Example 1: A teacher wants to teach
her student, Jorge, to tie his shoes. She
observes Jorges day and assesses when
naturally occurring opportunities to tie his
shoelaces occur (e.g., after coming back
from the playground to take sand out of his
shoes, after a swimming session, etc.). We
know that children with ASD often need
many, many teaching trials before they will
fully develop a skill. There may be limited
naturally occurring opportunities to practice a skill like tying shoelaces. The teacher
decides to create more such opportunities
for Jorge in a natural setting. She develops
a daily activity of doing relaxation training
for the entire class. This relaxation activity
involves removing the shoes and wiggling
the toes. She has just created five additional
teaching opportunities per week!
Example 2:
A treatment called Enhanced

Milieu Teaching (EMT) can be used to
improve social communication skills. EMT
involves arranging a childs social environment so that she is more likely to be highly
engaged in classroom activities and in
social interactions. The procedures used
to increase engagement include modeling appropriate social and communication

skills, providing necessary prompts, following the students lead to create teachable
moments, and making sure children get access to a rich schedule of reinforcement.
By structuring the learning environment in this way, your students with ASD learn
important social communication skills. When these strategies have been applied in
the past, skills have also been maintained over time and generalized to new situations (Hancock & Kaiser, 2002).
Example 3:
Jane is a student who often shows interest in cars. The paraprofessional working with Jane knows that the days teaching goals focus on color
identification and counting. He plans to use cars in the free play area to work on
these skills. However, when class begins, Jane shows an interest in balls. The paraprofessional still works on the concept of colors and counting, but follows Janes
interest in the balls. He waits for Jane to be motivated by the material (e.g., Jane
reaches for one of the balls) and then holds the ball slightly out of reach and asks
Jane to identify its color. He knows Jane will need prompting. So, as soon as he
finishes asking her to identify the color, he tells her the name of the color. He then
gives Jane the correctly colored ball. After he hands Jane each new ball, the paraprofessional retrieves the last ball that was used. At the end of the session, he asks
Jane to count each of the balls using a 1:1 correspondence.

We interact with other people because there is a payoff of some kind. We like to
spend time with others, enjoying similar activities and connecting with them. Are you
a more social person who spends most of your time interacting with others (through
phone, activities, etc.) or are you more of a homebody? There is natural variability in the
degree to which we each like to socialize.
While many children on the autism spectrum tend to spend less time interacting
socially than their peers do, this is not universally true. Some students on the spectrum
frequently try to interact with peers, but may do so in unexpected or socially inappropriate ways. Regardless of a students inclination toward social activities, developing
social interaction skills is important to achieving long-term success in life.
As mentioned in the previous section on

modeling, we all watch and learn. Sometimes
the watching is programmed; sometimes
it just happens naturally. Play groups in
preschool and kindergarten offer a naturally
existing modeling program to facilitate appropriate social, pre-academic, and behavioral
skills. However, children with ASD demonstrate a real deficit in their watching and
observational skills, and therefore cannot be
expected to benefit from naturally occurring
modeling without added structure.
In the life of a child with ASD, the role
of peers and siblings is important because
they are the most likely to be accessible and
competent models, and because the goal of
any intervention is to make the child more
successful with his peers in the natural environment. Although it is completely acceptable
to teach an 11-year-old to play appropriately
with an adult, success for that student in his
natural environment (i.e., school, classroom,
family gatherings, vacations, etc.) will largely
depend on his interaction with similar-age
peers and/or siblings.
Some of your students with ASD may
avoid their peers, so the idea of developing
an intervention reliant on peers may surprise
you. The behavior of peers may appear unpredictable or frightening for the child with ASD,
so we can understand that the child might
have a lower rate of initiating social interactions with peers than with adults. This is
why it is so essential to train peers in how to

facilitate positive interactions with the student
on the autism spectrum.
There are many different peer training
programs, including Project LEAP, peer networks, circle of friends, buddy skills package,
Integrated Play Groups, peer initiation training, and peer-mediated social interaction
training.
Peer training often begins with

careful selection of peers. Ideally,
these peers:
Are socially skilled
Are generally compliant with instructions
Have regular school attendance
Are willing to participate in training
Are able to imitate a model
Simply placing highly skilled peers near
a student with ASD is not likely to produce
favorable outcomes. Instead, you need
thoughtful planning. It is necessary to teach
peers how to get the attention of the child
with ASD, facilitate sharing, provide help
and affection, model appropriate play skills,
be a good buddy, and help organize play
activities.
Once the peers are trained, both groups
of children should engage with each other
in a structured play setting. This gives the
peers opportunities to use the skills they have
learned. At the same time, the educators can teach initiation strategies to the student
with ASD. As the school professional, your role is to provide prompts and feedback to
facilitate interaction between both groups.
Peer Training treatments:

Have been shown to be effective for children aged 3-14 years
Are associated with favorable outcomes for children diagnosed with autism and
PDD-NOS
Have been shown to be effective with target skills and behaviors, including:
Interpersonal skills (e.g., affection, complimenting)
Play skills (e.g., play organizers)
Social interaction (bids for attention, responding to questions, etc.)
Sharing
Offering and seeking assistance
Being a good buddy (staying, playing, talking with your buddy, etc.)
Consider the following examples of Peer Training treatments:

Example 1: Consider the cases of Fred and John. They each were diagnosed with
ASD and had older brothers who were not on the spectrum. Siblings often serve
as excellent interventionists if they are taught how to interact effectively with their
brother or sister with ASD. In this case, the older brothers were taught a number
of behavioral strategies to help increase Fred and Johns play activities (verbal and
nonverbal). The older brothers successfully used prompting (verbal and physical)
and reinforcement (verbal and tangible). In addition, adults implemented a time-out
component. By teaching the older brothers to interact more effectively with Fred
and John, the play skills of the two boys with ASD improved and were maintained
over time (Coe, Matson, Craigie, & Gossen, 1991).
Example 2:
Peer training can be effective not only in improving social interaction

skills, but also in reducing behaviors that make the student with ASD appear very
different from her peers. You probably serve students with ASD who engage in selfstimulatory behaviors (repetitive, nonfunctional motor mannerisms). By teaching
peers to get their friends to play with them using the strategies discussed earlier,
play skills of children with ASD have been increased and self-stimulatory behaviors
have been reduced (Lee, Odom, & Loftin, 2007).
Example 3:
As exciting as it is to see students with ASD improve their social interactions with peers following peer training, you may also notice that your student
with ASD still requires additional support to develop all of the skills he needs to
fully engage with his peers. Fortunately, peer training can be combined with other
strategies (e.g., direct instruction and written texts cues). By teaching the peer to
facilitate social interactions with the child with ASD and teaching the student with
ASD specific communication skills he may need, a higher quality of social interaction may result (Theimann & Goldstein, 2004).
It is important to keep certain factors in mind while you design peer training interventions. First, the age and skill level of the students (with and without ASD) should be
similar, so that it is relevant for both groups of children. In addition, the activities you
include in the session should address the interests and preferences of both groups of
students. This will ensure high levels of attention and engagement with the activity. You
should expect challenges with both maintenance and generalization of the targeted
skills, and should focus on addressing these challenges.

Pivotal Response Treatment (PRT) holds much in common with Naturalistic Teaching
Strategies (NTS). Both methods teach skills in the natural environment and create situations in which the student will be motivated to learn. The goal of PRT is to target pivotal
behavioral areas that may have a watershed effect on the development of many other
skills. PRT places a stronger emphasis on self-management than interventions associated with NTS. In addition, PRT is often used to target a broader range of skills (e.g.,
communication, social interaction, play, etc.).
PRT may be based on parental involvement in natural settings. An extension of the
natural language paradigm, PRT aims to teach a student to respond to various teaching
opportunities within his own environment, to increase independence from prompting/
coaching, and to minimize the time spent away from his natural environment (Koegel,
Koegel, & Carter, 1999).
Areas targeted by PRT include motivation to engage in social communication, selfinitiation, self-management, and responding to multiple cues.
Motivation is enhanced by increasing choice, building a direct response-reinforcer
relationship (i.e., there is a direct relationship between the reinforcer and the
activity in which you are engaged), interspersing mastered with novel tasks, and
reinforcing reasonable attempts.
Self-initiation involves teaching students to take action in the world. Because we
want them to be independent, we do not want children to wait passively for other
people to make positive situations occur.
Self-management involves teaching students to regulate their own behavior by
keeping track of their progress and accessing reinforcers for their successes.
Responding to multiple cues involves teaching students to respond to the diverse
statements of others, or to different kinds of materials (even if there is wide variability in the way things are said or the materials that are used).
Pivotal Response Treatment:

Has been shown to be effective for children aged 3-9 years
Is associated with favorable outcomes for children diagnosed with autism
Has been shown to be effective with target skills and behaviors, including:
Play skills
Consider the following examples of Pivotal Response Treatment:

Example 1: Communication is one of the most critical skills to target for students
with autism. Significant improvements in communication can result when PRT
strategies are implemented. These strategies include: varying the materials used
during teaching to avoid boredom; using natural reinforcers and making sure they are
available for attempts at communication; and teaching in the natural environment.
Using these kinds of strategies, students have learned to imitate the statements of
others (Koegel, ODell, & Koegel, 1987) as well as to increase their use of spontaneous utterances (Gillett & LeBlanc, 2007).
Example 2:
If you observe your students while they play, you will notice that there
is a great deal of diversity in the toys they use, the complexity of their play behaviors, and how creative they are during their play activities. Students with ASD often
have difficulty with symbolic play. For instance, students on the autism spectrum
are less likely to pretend that a plastic plate is a hat, or that a play stove is hot.
Instead, if they engage in appropriate play, they are more likely to use a toy exactly
as it was designed to be used.
PRT has been used to target symbolic play skills for students on the autism
spectrum. In this example, the adult interacting with the child used the following
strategies: following the childs interest, modeling how to play with the toys (including symbolic play), reinforcing attempts, using natural and direct reinforcers, and
taking turns. When improvements in symbolic play were noted, the student was
expected to demonstrate more creative play (i.e., reinforcers were available when
more complex play was demonstrated). By using these strategies, children between
the ages of 4 and 7 were taught to engage in more symbolic play (Stahmer, 1995).
These skills typically generalized to new toys, situations, and play partners. These
strategies have also been used to improve sociodramatic play (an advanced form
of symbolic play that includes skills like role playing, social interaction, etc.) (Thorp,
Stahmer, & Schreibman, 1995).
Example 3:
As we have noted previously, peer involvement in interventions can

lead to very beneficial outcomes. PRT strategies can be used not only by educators and parents, but also by peers to improve the social play skills of the student
with ASD. Teaching PRT strategies to peers has been shown to improve social play
activities (Harper, Symon, & Frea, 2008). These strategies include: gaining a peers
attention; varying the kinds of activities in which you engage; narrating play activities; reinforcing attempts to interact during play; and taking turns. In this case, the
peers learned these strategies during recess over the course of seven consecutive days. This means that peers were quickly taught to use PRT strategies that led
directly to more social engagement during play for the student with ASD.
Schedules
Isnt it nice when we can predict
what will happen next? When watching
a movie, you might not want to know
exactly what will happen. But in many
situations, we like to have an idea of
what to expect. Predictability in life is
generally comforting to us all. Imagine a
world in which someone in blue shorts
just ran into the school and started tickling you; or the administrative assistant
started singing tunes to the school over
the intercom system. These situations
seem unreasonable and unpredictable,
and would leave us uncomfortable, to
say the least!
Children with ASD tend to strive for
predictability more than most people.
This is because it is hard for them to pick
up on the subtle cues which signal to the
rest of us that something in the environment might be changing. Even things
that appear reasonable and predictable
to us do not always feel that way to students on the autism spectrum.
In our daily lives, we enhance our ability to predict future events by planning
and scheduling. We use our planners,
computers, and PDAs to schedule
appointments and meetings. Similarly,
the use of Schedules as an intervention
aims to promote greater independence
in individuals with ASD. The goal is to
target daily activities and, if possible, to

include planning for events on a daily,
weekly, or monthly basis.
Transitions may be better managed
with the use of schedules. A student
who does not enjoy academic work may
benefit from an intervention in which
his picture schedule is comprised of just
two pictures showing the first, then
contingencies. First he completes the
academic work and then he gets access
to a preferred activity. Gradually, you
can add more pictures as he masters
the use of the schedule and can tolerate increased demands before he gains
access to preferred activities.
Schedules vary in their presentation style. Educators have used various
media such as pictures (real photos or
Boardmaker), written or typed documents, or 3-D objects. These tools can
be as small as a 1 icon per board to
reflect a full days schedule, to a written
document that includes the full weeks
schedule in a grid format, to a running
list of to do activities with no time
specification.
The use of schedules may be as
simple as {1} placing pictures/texts on
the board at the time of the activity, {2}
pointing to the activity while engaging
in the activity, {3} taking the picture off
the board and {4} placing it in a done/
completed/finished bin/bucket/box/pile. More advanced schedules may involve the

student crossing out the activity she has completed, much as you would do with your
own to do list. Some schedules also include photos of the staff involved in the activity, location details, and materials that are needed.
The schedules theme lends itself to great variation in setting and application. Some
classrooms have a classwide schedule, and some use individualized schedules. Some
students set their schedule once a day; others set their schedules in the morning and
again in the afternoon. Some educators may make the schedule for the student or with
the student; others allow students to make their own schedules. In all instances, individualization is the key to ensuring the student benefits completely from the schedule.
Schedules have been shown:

To be associated with favorable outcomes for individuals with autism
To improve self-regulation skills
Consider the following examples of Schedules:

Example 1: The use of schedules can help students with ASD maintain their focus
through transitions in the classroom environment. In one study, students (7-8 years
old) were taught to use visual schedules to transition to and from four learning centers in a classroom (writing, reading, listening, and art center). Once teachers had
the students attention, they instructed the students to complete four activities. To
help the students transition successfully, they used pictures in a photo album in the
order in which the activities were expected to occur. These visual schedules have
improved on-task and on-schedule behavior for students with ASD (Bryan & Gast,
2000).
Example 2:
Schedules have been successfully used to address the aggressive and/

or disruptive behaviors of students with ASD. For instance, picture schedules have
been developed with Velcro placed on the back of each picture. The student can
be taught to match the picture on the schedule to the picture on the container that
includes his work material. When paired with reinforcement, this kind of schedule
has been shown to increase cooperative behavior and decrease aggression for a
preschooler with PDD-NOS (Dooley, Wilczenski, & Torem, 2001).
Example 3:
The transition from home to

school (and from school to home) can be
challenging to children with ASD. Teachers
may partner with parents to develop
and use schedules to reduce a students
level of discomfort with these transitions. Parents have successfully applied
photographic activity schedules targeting leisure, social interaction, self-care,
and housekeeping tasks. Schedules can
be presented in a three-ring binder with
one photograph per page. In one case, a
student was taught to point to the page,
get the materials needed, complete the
activity, clean up when done, check the
schedule again for next activity, and repeat
the same sequence (Krantz, Macduff, &
McClannahan, 1993).
Self-management has been widely

used to promote independence in children
with tasks in which adult supervision is
not needed, accepted, nor expected. Most
people naturally develop some degree of
self-management, but it often needs to be
programmed for individuals with ASD. If you
have ever been on and off a diet, tried to
improve your exercise habits, or endeavored
to build more activities into your schedule,
then you have probably tried to improve
your self-regulation through the use of Selfmanagement procedures.
Self-management
Independence is greatly valued in our

society because it increases the likelihood
of success in any situation and setting. A
dependent individual, on the other hand, is
limited in the range of social and general life
experiences he is afforded. Children with
ASD may not learn to adapt and change their
behavior based on naturally occurring cues
in the environment. Their inability to pick up
on these subtle cues and alter their behavior
accordingly will impede their success in many
situations.
Self-management has been shown:

To be an effective intervention for children
aged 3-18 years
To produce favorable outcomes for children
with ASD
Academic skills
Self-regulation
A student who uses self-management is
responsible for selecting reinforcers, monitoring and evaluating his own performance, and
independently gaining access to reinforcers
when a task is accurately completed (Pierce
& Schreibman, 1994). Self-management can
be used to teach the student to perform steps
that his front-line interventionist would otherwise do (e.g., identify target behaviors,
discriminate between correct and incorrect responses, record occurrences of target
behaviors, and deliver reinforcers) (Koegel & Frea, 1993).
Benefits of Self-management include:

Building awareness of your behavior
Accountability for carrying out a procedure
Direct and immediate self-feedback when recording your own data
Multi-tasking (i.e., managing your own behavior and recording it)
Decreasing social stigma that occurs when an adults assistance with simple and
personal tasks is required
Self-management begins with learning to perform each component of a task. When
a student first learns a new skill, instructors may need to use one of the other active
teaching strategies, such as live or video modeling.
Once the student learns each component of a task, he needs to evaluate his own
efforts to determine if he has accurately completed each component of the task. In
order to learn to evaluate his efforts, he needs to have:
Clear criteria established so he knows when he has succeeded and when he has
fallen short of the mark.
A systematic method for evaluating his performance. He might keep track of his
performance using checklists, wrist counters, velcroed smiley faces that move
from the incomplete column to the completed column of a task list, or any number of other strategies geared toward his interest.
A qualified person who can provide neutral feedback about the accuracy of the
recording. Almost everyone who starts evaluating his performance on a task
records inaccurate data (intentionally or unintentionally). Have you ever tried to
record everything you have eaten for a diet? Be honest! How accurate were you?
Instructors often need to give prompts (verbal and non-verbal cues) so students
can learn to correctly self-record their behavior.
This neutral, qualified person could

be anyone in the school system who
understands the self-management
system. They first need to focus on
rewarding accuracy in recording and
not get side-tracked by inaccuracies in
performance!
Example 2:
Self-management can
enhance the independent completion of
tasks. To enjoy the highest level of freedom in our lives, we all need to learn to
independently complete a number of daily
living tasks (e.g., setting the table, getting
dressed). The individual with ASD may
have mastered skills, but often lacks the
ability to independently perform them.
Integrating access to reinforcers is essential in promoting independent use of skills.
A qualified person who can teach the

child to seek and get access to reinforcers only when he has met the
pre-established criteria for success.
Often, the adult retains control over the
reinforcers.
One way to do this is to create a photo

album showing each step of an activity
and the materials needed for that activity.
The last picture shows the reinforcer. This
lets the individual with ASD know that
when she is done with the task, she will
gain access to the reinforcer (Pierce and
Schreibman, 1994).
Consider the following examples:

Example 1: Self-management may be a
natural evolution for a student who is successfully using schedules. Students with
existing schedules can often be taught to
increase their independence by changing
a schedule into a self-management system. For instance, one of your students
may already follow a schedule to transition
from one activity to the next. He may not
yet have developed the skill to determine
when any of the activities are completed
accurately, or perhaps he cannot yet
arrange for access to reinforcers to maintain his efforts. By teaching the student
to self-evaluate for accuracy, completion
of activities, and to provide self-reinforcement, you can help successful
transitioning to occur more independently.
Example 3:
Regular physical activity is

important for both long-term health and
as a natural way for students to actively
engage in leisure activities in their communities. Self-management can be used
to teach students to track their physical
activity. Reinforcers can be provided for
completing a set amount of exercise or
physical activity (e.g., snowshoeing and
walking/jogging) (Todd & Reid, 2006).
Additional strategies of prompting instruction and/or intervention should be planned
(Strain et al., 1994) until the task can be completed independently. Dependency on
prompts for some tasks (e.g., grocery shopping) may be acceptable as compared to
tasks where an adult prompt is intrusive (e.g., getting dressed).
You should plan to systematically fade adult or external, overt cues used during
self-management. In some cases, it may be necessary to continue using prompts over
a relatively long period of time in order to achieve a desirable level of self-management
across new behaviors.

Story-based interventions are similar to written scripts and Self-management in that
they involve written materials that are designed to increase independence. The most
well-known story-based intervention is Social Stories.
When using a story-based intervention, use written descriptions for:

The target behavior
The situations in which the behavior should occur
The likely outcome of performing the behavior, which often includes a description of
another persons perspective
All story-based interventions include information about the who/what/when/
where/why of the target behavior. Most stories are written from an I or some
people perspective, and they aim to increase perspective-taking skills. You can follow
the stories with discussion or comprehension questions to make certain the student
understands the main points. Students often receive reinforcement for reading the
story and performing the behavior correctly. In addition, the stories are sometimes
used to prompt the student in the natural environment. Some stories include pictures
to enhance comprehension of the skills.
Story-based interventions have been shown:

To produce favorable outcomes for individuals with autism and Aspergers
Syndrome

Social behavior
Choice and play skills
Understanding emotions
Mealtime skills
Self-regulation
Problem behavior
Story-based interventions are often used with students who have acquired reading
and comprehension skills. However, if a child has strong listening comprehension skills,
you might read the story to her instead of having her read it independently.
Example 1:
Story-based interventions can be effective in modeling socially

acceptable behavior. Consider the example of an adolescent who makes girls
uncomfortable because he stares at them. His teacher writes a story in which the
student learns to look at girls only briefly and then look away from them. His looking
at girls now more closely parallels the behavior of his fellow classmates, and the
girls may be more comfortable in his presence (Scattone, Wilczynski, Edwards, &
Rabian, 2002).
Example 2:
A special education teacher successfully implemented a Social Story

intervention with two children with severe autism to teach them choice-making
and appropriate engagement with play materials (Barry & Burlew, 2004). The Social
Story was paired with prompting and reinforcement in the form of praise. The
students each improved their ability to make choices without a great deal of teacher
prompting. They also went from spending no time playing appropriately during center activities to spending a minimum of 5-15 minutes playing appropriately.
Example 3:
Some students with ASD engage in very disruptive behavior (e.g.,

yelling, humming, loud noises, etc.). These behaviors can interfere with the smooth
running of a classroom and may even result in the placement a student with ASD
in a more restrictive environment. In one case, university researchers collaborated
with educators to develop and implement Social Stories paired with a reinforcement in the classroom. The study demonstrated the benefits of university-school
collaboration to reduce yelling and increase appropriate sitting for a young child with
ASD (Agosta, Graetz, Mastropieri, & Scruggs, 2004).
Each of the above examples followed the same general strategy. A story was written from the students perspective, and addressed the following questions:
What was the student supposed to do?
When was he supposed to demonstrate this behavior?
What would likely happen if he correctly performed the behavior (e.g., others
would like it)?
As you provide services to students with ASD, there are many interventions
from which you can choose.
Although a great deal more research is necessary to determine whether numerous interventions can lead to favorable outcomes, scientists have already conducted
enough research to show that many interventions are effective.
The great news is that there are now 11 Established Treatments that have sufficient
research support to demonstrate they are effective. The overwhelming majority of
these interventions were developed in the behavioral literature. Importantly, several
interventions were also influenced by fields such as special education and developmental psychology.
Selecting among these 11 Established Treatments may still pose challenges. This
is one of the reasons professional judgment (Chapter 3) and family input (Chapter 4)
are essential. We hope the upcoming chapters clarify the roles of professional judgment and family input in the delivery of evidence-based practice in the schools. It is
not possible to develop systematic capacity to deliver research-supported treatments
without first understanding the information contained in the present chapter. We hope
you are on your way to providing evidence-based practice to students with ASD in your
schools!
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Professional Judgment
& Data-based Clinical
Decision Making
As we go through our day-to-day lives, we sometimes base our decisions on
personal perspectives, or gut feelings. However, when it comes to making
treatment decisions for students with Autism Spectrum Disorders (ASD), we
must be much more systematic in our approach.
In previous chapters, we discussed the importance of making treatment decisions,
in part, on the strength of scientific evidence supporting the intervention. You have
learned that there are a number of treatments that are known to be effective. You
might ask, then, Cant I just go to the list of Established Treatments, close my eyes,
and pick one? We never recommend this kind of cookbook method to selecting
treatments. We believe your professional judgment is a critically important part of the
decision-making process. You must play an appropriately significant role in the selection, implementation, and assessment of treatments for your students with ASD.
So why is professional judgment so important?
Its important because selecting and implementing treatments is a complex process! There are an unbelievable number of intervention options available to school
personnel when they select treatments for students with ASD. Even if you restrict your
choices exclusively to treatments that have produced favorable outcomes in research,
you will need to select among the field of 11 identified by the National Standards
Project (NSP). This means your professional judgment will play a central role.
Your experience working with a specific child with ASD, your understanding of
interventions that have been effective or ineffective in the past, and your awareness of
the environment in which the treatment would be implemented will help you identify
which treatment might be most useful.
Since research is ongoing and best practices evolve, your professional judgment
also extends to your awareness of additional research support beyond those reported
in the Findings and Conclusions report (see Appendix).
In summary, professional judgment is certainly more than just relying on your
gut to tell you what to do. It involves {1} integrating information about a students
unique history, {2} an awareness of research findings that go beyond the Findings
and Conclusions report, and {3} the need to make data-based treatment decisions.
In the following pages, we explore these three critical components in more depth.
Understanding the importance of professional judgment will help you make your voice
heard when treatment decisions are made. Without your input, the best treatment
selection decisions may not be made.
Integrating Information About the Student

Your professional judgment comes into play when you have specific information that sheds light on the appropriateness of a treatment for a given
student.
Consider the case of Chun, a third grade boy diagnosed with ASD who has a history
of becoming obsessed with written materials (e.g., magazines, books). He engages in
high rates of self-stimulatory behavior and avoids school tasks when he has access to
written materials. In addition, whenever books or magazines are taken away from him,
he throws objects and hits anyone who is nearby.
Armed with this knowledge, you recommend against using a story-based intervention package. Despite its inclusion as an Established Treatment in the Findings and
Conclusions report, your professional judgment is that interventions requiring written
materials (like a Social Story) are not a good choice for Chun at this time.
This is not to say that a story-based intervention package will never be appropriate.
In this case, you would need to develop an intervention to reduce Chuns response
when written materials are taken from him. At that point, a story-based intervention
package may be beneficial for other goals you have set for Chun. Throughout this
process, your professional judgment (which is informed by both data and experience)
should influence treatment selection.
Awareness of Additional and New

Research Findings
The Findings and Conclusions report provides a strong foundation upon
which to base treatment decisions. Even so, there will be times to look
beyond the results of the report.
For example, the NSP included articles published before the fall of 2007. We are
happy to report that additional research has been conducted and published since this
date! If you are aware of additional well-controlled studies published after the fall of
2007 that show beneficial outcomes for a treatment, you might give serious consideration to the treatment.
Your awareness of additional research on any of the treatments for ASD will inform
your judgment about which interventions will be most appropriate for a student.
Articles that were excluded from the NSP may be one source of additional research
that you might consider. Similar to other evidence-based practice guidelines, the NSP
set clear parameters for its review and report.
For example, the following studies were excluded from the NSP review:
ASD articles across the entire lifespan. For example, the NSP did not include articles
on older adults. The focus of the review was on children or young adults who could
be served by early intervention and school programs or health and communitybased settings targeting this age group.
Articles in which individuals with ASD also had various co-occurring conditions (see
Differential Diagnosis and Co-morbid Conditions section of Chapter 1). If {a} an
individual has unusual disabilities and/or disorders in conjunction with ASD and {b}
a study shows the intervention is not effective, it is impossible to know whether
the treatment was ineffective for individuals on the autism spectrum or people with
both ASD and additional conditions.
Articles that focused on the change agents (e.g., educators, therapists, or parents). The goal was to focus on treatment as it relates to the individual with ASD.
By excluding all of the articles looking at older adults, individuals with co-occurring
conditions, and the change agent, the number of studies reviewed for a given treatment were at times reduced, and in some cases significantly reduced. For example,
this meant excluding almost all of the articles on Facilitated Communication. You will
find Facilitated Communication is classified as an Unestablished Treatment in the
Findings and Conclusions report.
As a professional, you are likely aware that many professional organizations advise
against the use of this treatment due to concerns regarding immediate threats to the
individual civil and human rights of the person with autism (American Psychological
Association, 1994). These advisements were written based on all of the research that
had been published to date on Facilitated Communication. In this case, your professional judgment should also play a role in treatment selection.
You may also be aware of additional studies beyond the ASD literature that should
influence your decision-making process. Whenever possible, you should make decisions about the effectiveness of a treatment based on research involving the specific
population you are serving. That is, if you serve a child on the autism spectrum, you
should make treatment decisions based, in part, on the scientific evidence supporting a
given treatment specifically as it pertains to that population.
There may also be occasions when information from the NSP or similar projects
must be supplemented by research in other areas. You may have information about
treatments for symptoms that can co-occur with ASD and are the source of concern
for the student. For example, some adolescents with Aspergers Syndrome may experience anxiety or depression. There are research-supported treatments for anxiety and
depression for individuals who are not diagnosed with an ASD. Your awareness of this
important literature should assist in treatment selection.
We hope we have made it clear that your professional judgment can and should play
an important role in treatment selection. Further, professional judgment should always
be informed by data. For this reason, we spend the rest of this chapter discussing data
collection procedures, strategies for analyzing data, and decision-making guidelines
for modifying treatments based on data. After all, treatment selection is only the first
step in a dynamic process. We should all be prepared to consider alternate treatment
choices if the data show that an intervention does not result in timely progress for
students targets.
Data Collection
Data collection is essential in your work with students with ASD. It is relevant whenever you develop an intervention designed to increase skills or to
decrease behaviors that interfere with life functioning. Why is data collection so critical? Collecting data before and after you put an intervention into
practice helps you assess whether your student is making progress.
We all tend to rely on anecdotal evidence (e.g., what we happen to notice, what
our gut tells us, etc.). Although it seems helpful, it is often unreliable. Therefore, we
should only use anecdotal evidence alongside empirical evidence. Consider a behavioral package treatment (token systems) as an example. Token systems are commonly
used in school and home settings. When educators and parents meet to discuss a
students behavior, they might also discuss the use of token systems in the classroom.
In this example, Johns parents ask if the token system is effective with their son.
If Johns teacher doesnt collect data regularly, her response might be influenced
by a number of factors. If John has had a good week, she might say, John seems
to be talking out of turn much less frequently in the classroom since I started using
the token system. On the other hand, if John had a particularly bad day, she might
respond more negatively: It doesnt seem like the token system has affected Johns
talking out much at all. We have all made comments like these from time to time. But
consider the downside of this type of anecdotal evidence:
We are more likely to remember what has happened in the last day or two than
how John has responded since the token system was introduced.
Human beings tend to look for confirmatory evidence. If we believe the token system will be effective, we are more likely to pay attention when John is doing better.
If we believe John is not likely to respond to the token system, we are likely to pay
attention when John is breaking the rules.
Educators spend much of the day multi-tasking (i.e., providing discipline, teaching lessons, grading papers). When you are this busy, you are more likely to notice
when things go wrong than when things go right.
Can you really be expected to accurately recall the effectiveness of an intervention
over the course of several weeks or months? No. Data collection is important because
it provides you with a firm basis on which to draw conclusions and make decisions
about intervention effectiveness. Before you can do so, you need a foundation in data
collection procedures.
The idea of collecting data can seem overwhelming. Here are a few recommendations for building
data collection into your daily activities:
Use efficient data collection techniques. You do not typically need to collect data throughout the
entire day.
When possible, select data collection procedures that can be used while you perform your other
essential duties (see Procedures for Collecting Data section).
Get help while you perform essential duties. The school psychologist, behavior analyst, principal, or other professionals can often assist with data collection.
Setting Goals and Defining Target

Behaviors
Setting Goals
School professionals typically have two goals when targeting behavior change.
First, they may try to decrease maladaptive or problem behavior. Behavioral reduction interventions are put in place when students show excessive behaviors (e.g.,
self-stimulatory behavior, aggression, self-injury, disruptive behavior, etc.). Behavioral
acceleration interventions are put in place when students show a deficient level of
responding (e.g., adaptive, communication, social functioning, etc.). Before data collection begins, you must develop a clear goal for the intervention, irrespective of whether
you plan to put a behavioral reduction or behavioral acceleration intervention into place.
There are two rules that can help you identify an appropriate goal.
The first rule is the dead mans test. Whenever possible, it is best to write a target
behavior so that it clearly identifies what the student should do (instead of what she
should not do). As you develop your goal, make sure it passes this test.
The dead mans test simply requires that your goal does not reflect an activity a
dead man might demonstrate. For example, lets say your student, Mario, obsessively
sharpens his pencil. The constant pencil sharpening interferes with the time he spends
on his assigned tasks and disrupts the students around him. You set a goal of Mario
will not sharpen his pencil in class. Unfortunately, your goal does not pass the test,
since a dead man is perfectly capable of not sharpening his pencil! Instead, consider
setting a goal of Mario will sharpen his pencil only once per class. Can a dead man
sharpen his pencil once per class? Not unless he is a zombiewhich is a topic well
beyond the scope of this manual!
The second rule is related to relevance. Before we begin the process of data collection, we need to make certain a behavior should actually be targeted for change.
You can determine this by identifying whether a change in the behavior would actually produce meaningful improvements. Learning to communicate, play with peers, or
study often leads to meaningful improvements in a students life. Similarly, reducing

disruptive behavior may lead to improvements in a students social interaction with
peers and increase the amount of time spent on task.
There are two issues to consider before you make a final determination
about a goal:
1. Goals should be developmentally appropriate. A student who can label 200 pictures
of objects but cannot request one of those items without beings asked What do
you want? should not begin working on the next 200 labels until basic requesting
skills have been targeted for improvement.
2. Some behaviors are only irritating to adults who share the life of an individual with
ASD. A child who yawns excessively might distract the teacher at the front of the
class. But if the student gets his work done and his classmates do not seem to
notice, this disruptive behavior should not necessarily be targeted for change.
You will need to use your professional judgment to identify an achievable goal for
the student. For example, you may attempt to decrease the number of times a student
talks out of turn. A baseline frequency count reveals that the student talks out of
turn 100 times during an average school day. You must decide what a reasonable and
achievable goal may be for the student and whether your goals should shift over time.
Your professional judgment tells you the final goal should be that the student does
not talk out of turn more than the other students in the class. You collect data on the
frequency of talking out of turn for students in your class and decide it is acceptable
to talk out of turn eight times during each school day. You decide that going from 100
to eight times a day is not going to happen overnight, so your first goal is to reduce
his talking out to 75 times a day. You know that this number is still excessively high,
but you want him to be successful. You are now ready to proceed to intervention, with
ongoing data collection to assess its effectiveness. You will need to set a number of
intermediary goals (e.g., 50, 25, 10) before you expect him to talk out eight or fewer
times per day.
Defining Target Behaviors

As you have established your goal, you will need to clearly define the target behavior. The definition should be written with enough clarity that a stranger would be able to
identify the presence or absence of the target behavior. Lets take the example of the
following target behavior: Given the choice of three pictures, the student will point to
a picture of the correct animal in receptive labeling tasks. A stranger (who happens to
be familiar with a speech-language pathologists jargon) should be able to identify the
presence of the target behavior (e.g., the student correctly pointed to the picture of
the dog when the teacher said Point to the dog.) or the absence of the target behavior (e.g., the student incorrectly points to the picture of a goat when the teacher said
Point to the dog.).
You will note that the target behavior identified here is very specific, it is observable,
and it can be easily measured. There are many behaviors that are written in a vague
way. To state the same goal as The student will recognize the correct picture when
completing receptive labeling tasks is not very measurable. How do you know if the
student recognizes it or not? Can you actually observe someone recognizing the correct picture? No. It also does not include what the parameters of the observation may
involve. For example, are you supposed to show the child one picture, two pictures,
three pictures, or more when completing this receptive labeling task?
You should be able to answer each of the following questions when

evaluating your definition:
Is the definition specific?
Is the target behavior observable?
Is the target behavior measurable?
Procedures for Collecting Data

There are many data collection options (Alberto & Troutman, 2003; Webber
& Scheuermann, 2008). Some data collection procedures that are used most
often include frequency, time sampling, duration data, and latency data.
Frequency. Frequency data involve counting the number of times a behavior has
occurred within a given time period.
Time sampling. Time sampling data involve determining whether or not behaviors
occur within a specific interval of time.
Duration. Duration data involve determining the length of time over which a behavior occurs.
Latency. Latency data involve the length of time that passes between when an
instruction is delivered and a behavior is initiated.
The type of behavior you attempt to increase or decrease will determine the type of
data collection technique you should use. The following discussion of these techniques
may help you decide which option is most appropriate.
Frequency Data
When you want to record the frequency of a behavior, you make a tally mark each
time the targeted behavior occurs. At the end of the observation period, you count the
number of tally marks you have made and this represents your frequency count.
Before beginning frequency data collection, you need to determine the length of
the observation period. Should frequency data be collected during the first or last 10
minutes of class? Should they be collected during the entire class period? Should they
be collected whenever the child is in the classroom? Or, should the data be collected all
day longacross every setting in which the child spends time?
Frequency data collection is typically used when a behavior has a distinct beginning
and end. For example, you can use a frequency count to record number of words read
aloud, math problems completed independently, or hand slaps on a desk. Figure 1
provides an example of a frequency count data sheet.
Figure 1}
Frequency Recording Data Sheet
Student: Jose
Date: 10/2
Record a tally mark (/) for each occurrence of the target behaviors during the specified time period. Record a 0 if no target
behavior occurred during the specified time period.
Aggression is defined as any occurrence of kicking, hitting, pinching, or throwing objects at another person. Attempts to
kick, hit, pinch, or throw an item are also recorded.
Talking Out is defined as any occurrence of Jose speaking without permission during group activities in the classroom.
Aggression
Talking Out
Staff Initials
////
//
SF
9:15-9:30 a.m.
SV
9:30-9:45 a.m.
///
LB
9:45-10:00 a.m.
////
LB
10:00-10:15 a.m.
///
SF
10:15-10:30 a.m.
SF
10
9-9:15 a.m.
Total
There are advantages and disadvantages to collecting frequency data. Recording

frequency data is relatively easy. Unfortunately, it may not always best represent the
students problem behavior. For example, you only make one tally mark if a student
throws a tantrum for 60 minutes, 30 minutes, or five minutes. If you use frequency
data collection procedures for a problem like tantruming and you put an intervention in
place, it is harder to see improvement when the tantrum decreases in length from 60
minutes to five minutes, since a tally mark records the occurrence of a behavior, but
not its duration.
Time Sampling
Time sampling methods vary but
essentially require breaking down an
observation period into smaller intervals
and then recording whether the behavior
occurred during the interval (SulzerAzaroff, 2008, p. 208). For example, a
five-minute observation period can be
divided into 10-second intervals. There
would be 30 opportunities to mark
the presence or absence of the target
behavior.
This data collection method is used
most often when a behavior occurs at
relatively high rates or does not have a
distinct beginning and end.
Time sampling methods require the
use of a timer to mark the beginning
of each interval. Often, professionals
using interval recording procedures use
a watch with an interval setting, or they
listen to a prerecorded CD of someone
marking every interval.
Consider the time sampling data
sheet in Figure 2. Lets say you have
made the decision to collect data at
three different five-minute observation
periods during the school day. The first
five-minute observation will occur at
the beginning of English class, between
9:40 a.m. and 9:45 a.m. You have
clearly defined Staceys self-stimulatory
behavior and stated it at the top of the

data sheet. You have a prerecorded
CD that clearly states the beginning
of the observation period (e.g., it says
Observation begins now.). At the
end of the first 10-second interval,
the recording states 1-1 to indicate
the end of the first interval of the first
minute. You now record the presence or
absence of the self-stimulatory behavior.
Since Stacey engaged in self-stimulatory
behavior during observation interval
1-1, you use a plus sign + to record
the presence of the self-stimulatory
behavior. The self-stimulatory behavior
occurs during the first three observation
intervals.
During observation interval 1-4,
Stacy stops engaging in self-stimulatory
behavior. You record the absence of
her self-stimulatory behavior by marking a minus sign in interval 1-4. At
the end of the five-minute observation
period, you count the number of intervals in which the behavior occurred so
you can calculate the percentage of
intervals in which that behavior occurred.
In this case, self-stimulatory behavior
was recorded in 13 of the intervals. By
dividing 13 by the total possible of 30
intervals, and then multiplying by 100,
you determine that Stacey engaged in
self-stimulatory behavior during 43% of
intervals.
Figure 2}
Interval Recording Data Sheet
Student: Stacey
Date: 4/9
Self-stimulatory Behavior is defined as any occurrence of Stacey rocking her upper body in a back and forth motion while seated in her
chair.
Record self-stimulatory behavior during three 5-minute observations each school day.
The 5-minute period is divided into 10-second intervals. Self-stimulatory behavior is recorded during a partial interval. Record a + if the
behavior occurs during the interval and record a - if the behavior does not occur during the interval.
Time Start:
9:40 a.m.
Time Start:
Time Start:
Time End:
9:45 a.m.
Time End:
Time End:
1-1
1-2
1-3
1-4
1-5
1-6
2-1
2-2
2-3
2-4
2-5
2-6
3-1
3-2
3-3
3-4
3-5
3-6
4-1
4-2
4-3
4-4
4-5
4-6
5-1
5-2
5-3
5-4
5-5
5-6
1-1
1-2
1-3
1-4
1-5
1-6
1-1
1-2
1-3
1-4
1-5
1-6
2-1
2-2
2-3
2-4
2-5
2-6
2-1
2-2
2-3
2-4
2-5
2-6
3-1
3-2
3-3
3-4
3-5
3-6
31
3-2
3-3
3-4
3-5
3-6
4-1
4-2
4-3
4-4
4-5
4-6
41
4-2
4-3
4-4
4-5
4-6
5-1
5-2
5-3
5-4
5-5
5-6
51
5-2
5-3
5-4
5-5
5-6
Number of intervals with + 13
Number of intervals with +
Number of intervals with +
Number of intervals with 17
Number of intervals with
Number of intervals with
% of intervals target
behavior occurred: 43
behavior occurred:
behavior occurred:
There are several different types of time sampling procedures. These procedures
differ based on how you decide to record the occurrence of the target behavior.
The most common forms of time sampling procedures include:

Partial interval. The observer records the presence of the target behavior (with a
+) if the behavior occurs at any point during the interval. The observer records the
absence of the target behavior (with a ) if the behavior does not occur during the
interval.
Whole interval. The observer records the presence of the target behavior if the
behavior occurs during the entire interval. The observer records the absence of the
target behavior if the behavior does not occur throughout the entire interval.
Momentary time sampling. The observer records the presence of the target
behavior if the behavior occurs at the end of a specified interval. This means the target behavior is recorded only if it is present at the exact moment the interval ends
(e.g., when the recording states 1-4). Even if the behavior occurs at other times
during the interval, if it does not occur at the exact moment when the interval ends,
the observer records that the behavior was absent.
There are advantages and disadvantages with each of these time sampling procedures. For example, momentary time sampling is much easier, but it may not
accurately represent a target behavior. A student could spend much of her time
engaged in inappropriate behaviors, yet no instances of problem behavior would be
recorded because of the timing of her actions. On the other hand, partial interval
recording may easily result in recordings of inappropriate behavior, but it might not
be very sensitive to improvements because behaviors are recorded even if they are
fleeting.
There is no perfect data collection system! You simply need to consider these points
to minimize your greatest concerns about the accuracy of the data.
Duration
A measure of duration simply means
that you record the start and stop of a
behavior (e.g., the length of a tantrum). This
generally requires the use of a stopwatch. An
advantage of duration recording is that you
manage to capture all of the problem behavior. That is, you record every moment of the
problem behavior. On the other hand, it also
has its limitations. For example, completing
other activities while you collect data can be
challenging. Also, for some behavior, it is hard
to know when the beginning and the end of a
target behavior occurs. You can clarify exactly
what should be considered an instance of
a target behavior by writing a very careful
definition. Lets use our tantrum example to
consider the question, What is a continuous
tantrum? That will require you to answer various questions to arrive at a specific definition.
Do you stop recording when the child has
to take a breath to inhale? He did stop
screaming at that point.
Do you stop recording if the child stops
flailing for two seconds but then starts up
again?
Latency
Like duration data, latency data are directly
related to the concept of time. While duration recording focuses on the length of time
a behavior actually occurs, latency recording
focuses on the length of time that passes
between when the instruction is delivered
and a target behavior occurs. Similar to duration data, a stopwatch is usually required for
latency data.
Why would we want to focus on the
length of time before a target behavior
occurs? In order for most people to be
successful, they need to be able to quickly
respond to demands in their environment.
Many students (including those on the autism
spectrum) do not jump to complete an activity the moment they receive an instruction.
Some students spend a lot of time looking
at materials instead of getting started with a
project, or delay turning to the right page until
a minute or two after the other students do.
These students are more likely to miss out
on instructional time and be unable to keep
up when they do initiate the task. Latency
recording is a perfect tool in these situations.
Do you stop recording when the childs volume reaches a low level even though she
is still whining and arching her back?
Additional Data Collection Considerations

The data collection procedures we have addressed to this point are extremely versatile. You can use the same data collection methods (i.e., frequency, time sampling,
duration, and latency) for behavioral reduction or behavioral acceleration.
An often overlooked way of collecting data is to monitor permanent products such
as completed worksheets or homework assignments. Permanent products are ideal for
the classroom setting because a good deal of academic work lends itself to these measures. Like the other data collection procedures we have described, these permanent
products can be used both as baseline and intervention data. Permanent products are
used for behavioral acceleration interventions (i.e., to increase academic success).
Self-monitoring is another data collection method that is not used frequently
enough. Self-monitoring systems require the student to record the occurrence of
his own target behaviors. This data collection method can be applied with behavioral
reduction and behavioral acceleration interventions. There are many studies suggesting
that self-monitoring systems can be effectively implemented in the classroom setting
(e.g., Cole & Bambara, 1992; Mithaug & Mithaug, 2003).
There are several advantages to self-monitoring. For example, self-monitoring is
efficient for the smooth running of the classroom. If the teacher, paraprofessional, or
school psychologist does not need to consistently spend time collecting data on a students progress, their professional skills can be used in other essential ways. Further,
learning to monitor their own activities is an important skill for all students. To best
support students with ASD, we need to take advantage of any strategies that lead to
greater independence.
Please see the Self-management section in Chapter 2 for a more detailed
description of self-monitoring procedures and the process of teaching students selfmanagement skills. You will also learn why self-monitoring data are not the ideal
baseline data. Hint: You might need to collect your own baseline data because students are not very accurate when they first learn to record their own behavior!
Using Data to Establish Baselines

We recommend that data be collected before you implement an intervention.
The data you collect before beginning treatment are called baseline data.
Without collecting baseline data, it will be impossible to clearly show that the
intervention you put in place have led to student improvement. Baseline data
collection need not be tedious or time-consuming once you have a system in
place.
We recommend the following steps:
1. First, decide on the type of data you will collect (e.g., frequency, duration, etc.).
2. Second, decide the time of day or the type of activity for which you will collect
data. Also determine the minimum number of days you will collect baseline data. At
least three data points are required to identify a trend (see data analysis section for
details).
3. Third, gather the tools you will need to collect the data (e.g., data sheet, timer,
pencil). Educators can access a number of examples of data collection sheets online
or in various textbooks and manuals (e.g., Alberto & Troutman, 2003; Webber &
Scheuermann, 2008).
Intervention Data
Once you have identified your goal, its time to implement the intervention.
You will have selected the intervention based on research findings (see
Chapter 2), the professional judgment of staff involved (this chapter), family
input (see Chapter 4), and the capacity to correctly implement the intervention at this time (see Chapter 5). You will need to collect data during the
intervention phase so you can determine whether the treatment you are
implementing is working.
There is no doubt that it takes time and energy to accurately implement an intervention. This can take time away from some of your usual activities,but you know its
worth it if the student makes progress. If you do not collect data during the intervention phase, it might be hard to know if the treatment is working. Your time and energy
are too valuable to waste. More importantly, you do not want to continue using an
ineffective intervention for the students in your care. For the student who talks out
an average of 100 times per day, what are the odds you will notice if it drops to 90 or
increases to 112 unless you collect data?
You must analyze and compare data between baseline and intervention conditions
to determine what to do next. You may decide to continue with the intervention if you
see improvements based on the comparison of baseline and intervention data. Or you
may decide to revise the current intervention or implement an entirely new intervention if it becomes clear things are not improving or are getting worse!
Ongoing data collection helps you to determine how changes in the intervention
affect the targeted behavior. It is important to use the same data collection procedure
during both baseline and intervention phases.
Graphing Data
Once you have collected baseline and intervention data, what do you do
with them? Is there an easy way to see if the intervention worked? There
is. Graphing is a useful tool that can help you make decisions and use your
professional judgment (Alberto & Troutman, 2003; Cooper, Heron, & Heward,
2007).
Looking at tally marks on a data sheet can be informative. But what happens when
you need to look across 5, 10, or 20 data sheets? Putting the data into a graph allows
for easy interpretation. Line graphs are commonly used to track changes in behavior
over time (e.g., Carr & Burkholder, 1998). Basic computer software such as Microsoft
Excel can be used to generate a simple but effective graph.
On a line graph, each data point represents one data collection session (e.g.,
one school day, one class period, etc.). A vertical line (i.e., phase line) can be drawn
between the baseline and intervention phases to indicate the introduction of the intervention. All data points in the same phase are connected by a line, but data points are
not connected across phases (see Figure 3).
Phase lines can also be drawn at various points to indicate where a change in the
intervention occurred. For example, if you learned that a student started on a new
medication while you were implementing a new intervention, you would draw another
phase change to show the new intervention phase (intervention 2: school intervention
+ medication). This would reflect the multi-component aspects of treatment that may
be influencing the students behavior (see Figure 4).
Figure 3}
Graphical Representation of Data
Aggression
14
Baseline
Intervention
12
This phase line separates the baseline and

intervention phases
Frequency
10
Each observational session gets its own data point
8
6
Data points within the same phase are connected

by a line
4
2
9
11
/0
2/
10
2/
2/
2/
9/
/0
09
09
8/
09
2/
7/
09
6/
2/
5/
2/
2/
09
09
4/
3/
2/
2/
2/
09
09
School Day
Figure 4}
Showing Changes in Phases When Modifications to Treatments

are Made
Shanes Self-Injurious Behavior

# of slaps to face or head
60
Baseline
Intervention 1
Intervention 2
50
40
30
20
10
0
1
School Days
10
11
12
13
14
Visual Analysis of Data

Once youve graphed your data, you can begin to visually analyze your
results. You will want to inspect the line graph to determine whether the
behavior is changing and, if so, whether the change occurred in the desired
direction. Ideally, the change from baseline to intervention is so fast and dramatic that the improvement will just jump out at you.
Unfortunately, that may not always be the case. Interpreting the graphed data is
easier if you account for stability and trends in the data. Also, the percentage of overlapping data points aids in the interpretation of data (e.g., Alberto & Troutman, 2003).
We will discuss each of these concepts in more detail.
Stability simply refers to how consistent the behavior is over time. Lets apply the
concept of stability to James, a fifth grade student with ASD. James is capable of
doing his work when you can get him on task. Unfortunately, you believe he stares
off (e.g., looks out the window, gazes at the ceiling, etc.) too much during his social
studies class. You decide you need baseline data on James off-task behavior and you
select a partial interval recording system. The school principal completes five-minute
observations during social studies for a week because she does not want data collection to interfere with your teaching.
You determine that James was off-task during:

23% (7 out of 30) of the intervals on Monday
20% (6 out of 30) of the intervals on Tuesday
20% of the intervals on Wednesday
23% of the intervals on Thursday
20% of the intervals on Friday
When you implement your intervention, the principal collects the following
data and you determine James was off-task during:
7% (2 out of 30) of the intervals on Monday
3% (1 out of 30) of the intervals on Tuesday
7% of the intervals on Wednesday
3% of the intervals on Thursday
3% of the intervals on Friday
You graph your data (see Figure 5) and see that there is great stability in James
off-task behavior in both baseline and intervention phases. It is easy to see that the
intervention was effective because James behavior has been so consistent in both
baseline and intervention phases. The good news is that he is clearly improving.
Figure 5}
Graphical Representation of James Off-task Behavior

James Off-task Behavior
100
Baseline
Intervention
Percentage of Intervals
90
80
70
60
50
40
30
20
10
0
1
Social Studies Classes
10
You then contrast James performance with another student in the

class. Kelly is a student with Aspergers
Disorder who also experiences problems
with concentration. While collecting data
on James, the principal also collected
data on Kellys off-task behavior. Her
data are graphed in Figure 6. You see
that there is little stability in the time she
spends off-task.
High variability may indicate an
unidentified environmental variable that
affects the target behavior on some
days but not others. You see that Kelly
was highly on-task on Tuesday and
Friday during the baseline condition. You
remember that she asked to use the
restroom before class began on each of
these days.
Armed with that information, you
develop an intervention in which you
give Kelly the opportunity to use the
restroom each day before social studies.
The lack of stability in Kellys baseline
data makes it a little more challenging
to interpret the outcomes. If you based
your decision exclusively on stability, you
might interpret the data to mean that the
intervention was not effective (because
there is still not a perfectly stable pattern
of responding). But you realize there are
more indicators that aid in interpretation

of visually presented data. You also see
that she spends more time on-task at
the end of the first week of intervention.
You decide to consider one of the other
key indicators of intervention effectivenesstrendsbefore interpreting
these data.
Trend refers to the direction of change
across data points within a phase (e.g.,
during baseline or the period of time
in which a treatment is being implemented). There are several ways to show
a trend. The easiest way is to visually
determine what line best describes
all of the data. You can draw this
trend line using a program like Excel. If
you would rather use a mathematical
approach to calculating the trend line, we
recommend the chapter on single-subject designs in Applied Behavior Analysis
for Teachers (Alberto & Troutman, 2003).
Analyzing trends in the data will help
determine if behavior change is moving
in the desired direction. Ideally, when
implementing a behavior reduction
intervention, the desired effect would
be a decreasing (or descending) trend
relative to baseline. In contrast, when
implementing an intervention to increase
behaviors or skills, the desired effect
Figures 6a and 6b} Graphical Representation of Kellys Off-task Behavior

(without and with trend line, respectively)
Kellys Off-task Behavior
100
Baseline
Intervention
90
80
70
60
50
40
30
20
10
0
10
10
Kellys Off-task Behavior

100
Baseline
Intervention
90
80
70
60
50
40
30
20
10
0
would be an increasing (or ascending) trend relative to baseline. As mentioned earlier,

you will need to collect at least three data points per condition. Identification of a trend
requires at least three data points and often may require five or more. It can be difficult
to identify a trend when the increase or decrease in behavior is gradual over time.
Lets look back at Kellys off-task behavior (see Figures 6a and 6b). If you were to
draw a line that best represents all of the data in the intervention phase, you would see
a descending trend. Because our goal is to decrease off-task behavior, the descending
trend tells us our intervention is leading to favorable outcomes.
Percentage of Overlapping Data Points (POD) refers to the percentage of data
points in one condition (e.g., baseline) that falls within the range of a second condition
(e.g., intervention phase). POD is one indicator of treatment effectiveness.
More effective intervention data will generally produce lower percentages of
overlapping data points (e.g., less than 20%); less effective interventions will produce
higher percentages of overlapping data points (greater than 30%). Lower percentages
of overlapping data points indicate that the difference between baseline and intervention phases are so robust that there is an easily noticeable difference between baseline
and intervention. That is, the difference is large enough that almost none of the data
points overlap.
Calculating the Percentage of Overlapping

Data Points
There are several steps to calculating POD. The process of calculating POD is easy
once you have done itbut the language used to describe the process is cumbersome! Try not to be overwhelmed when you review the steps. In the end, you are only
trying to figure out what percentage of the data points in baseline overlaps with the
data points in your intervention condition.
See Figure 7 to help illustrate the following narrative description:

Step 1:
Identify the range of data points for condition 1 (e.g., baseline). You determine the range by identifying the lowest and highest numbers in the condition.
For example, if your goal is to increase the number of social initiations your student
Figure 7}
Graphical Representation of Calculating Percentage of

Overlapping Data Points
Calculating POD
11
Baseline
Intervention
Step 2: Count # of data points in intervention (5)
10
9
# of Initiations
Step 1: Establish Range (3-5)
7
6
5
4
Step 3: Count # of data points in intervention that

overlap with from step 1: {1}
3
2
Step 4: Divide # identified in step 3 by #

identified in step 2: 1/5 = .20 x 100 = 20% POD
1
0
1
5
School Days
10
makes toward his peers, you might measure the frequency of social interactions
during recess. The fewest number of times Jacob initiates with peers in baseline is
three; the greatest number of times Jacob initiates with peers is five. The range you
calculate is: 3 5.
Step 2:
Count the number of data points in condition 2 (e.g., intervention).
In Jacobs case, you collected data while implementing your intervention during five
recess periods. The number of data points you calculate is 5.
Step 3:
Identify the number of data points in condition 2 that fall within the range
of condition 1. (In this case, the number of data points in the intervention phase that
fall within the range in the baseline phase. Note the range was calculated in step 1.)
You then examine Jacobs frequency of initiations with peers for each day of
intervention. You compare each data point to the range of social initiations Jacob
demonstrated during baseline. That is, you compare each data point in intervention
to the range you calculated in step 1. If a data point falls within the range for baseline (which you calculated to be 3-5), you count that as an overlapping data point. If
a data point falls outside the range for baseline, you do not count that data point. In
Jacobs case, there is one data point that falls within the range for baseline.
Step 4:
Divide the number of data points identified in step 3 by the number of data
points established in step 2. Multiply by 100 to calculate the POD.
Your last step is to calculate the percentage of data points in Jacobs intervention
condition that overlap with the data points in the baseline condition. You determined
that there was only one data point in intervention that overlapped with the range
you calculated in baseline. To calculate the POD, you divide the one data point that
overlaps in the intervention condition by the total number of data points in the
intervention condition. You already calculated the total number of data points in
intervention to be 5 (see step 2). You apply the formula described above to derive
the following POD: 1/5 = .20 X 100 = 20%. Your POD is 20%.
Lets look back at James data to compare the baseline and intervention phases
(Figure 5). The intervention was so effective that there are no overlapping data points.
Unfortunately, not all of our interventions produce such dramatic improvements.
Figure 8 provides an example of a behavior reduction procedure that resulted in a relatively high POD (i.e., most of the data points across baseline and intervention phases
overlap). The intervention depicted in Figure 8 is not considered effective, in part,
because of the high percentage of overlapping data points.
Figure 8}
Example of Ineffective Intervention: High Percentage of

Overlapping Data Points Between Baseline and Intervention
Aggression
14
Baseline
Intervention
12
Frequency
10
8
6
4
2
0
1
School Days
Challenges in Visual Analysis

As we have stated previously, stability, trend, and overlapping data points
are indicators of intervention effectiveness. However, visual analysis often
requires that you give lesser importance to one or more of these indicators.
For example, Figure 5 shows James off-task behavior during baseline and intervention phases. Its clear that there is a great deal of stability in the data that makes it easy
to see the intervention was effective. You can calculate the POD and see that none
of the data points in the baseline phase overlap with the data points in the intervention phase. But what about trend? We do not need to see a descending trend in this
case because the combination of stability in conditions and POD clearly demonstrate
improvements in James off-task behavior.
Interpreting Kellys data is more challenging (see Figures 6a and 6b). The baseline condition is not stable and there is a high POD across baseline and intervention
phases. But when you examine the data in the intervention phase, it is clear there is
a descending trend. Kellys off-task behavior is very low by the end of the intervention
phase, which suggests she is improving. When all of these indicators are taken into
consideration, you decide that you may need to collect additional data so that you can
be certain about the effectiveness of the intervention (see next section on details).
Ironically, an excellent intervention can produce a high POD (although this rarely
happens). This exception is as follows: if you have nearly perfect trends in one direction for baseline phases (e.g., ascending trends) and nearly perfect trends in the
opposite direction for intervention phases (e.g., descending trends), you will have a
high POD. However, the nearly perfect trends suggest that the intervention is very
effective.
Consider the following example. Shaliqua is a fourth-grade student with ASD. She
has recently started making inappropriate vocalizations that interrupt the students
around her. You begin collecting baseline data and find that the frequency of these
inappropriate vocalizations seems to be increasing (see baseline phase of Figure 9).
Figure 9}
Example of Exception to the POD Rules
Exception Rule to Interpretation of POD
# of Inappropriate Vocalization
16
Baseline
Intervention
14
12
10
8
6
4
2
0
1
10
School Days
You decide to put a Self-management intervention in place. Shaliqua learns to correctly record the frequency of her vocalizations and to get access to reinforcers if she
remains quiet. The frequency of inappropriate vocalizations quickly begins decreasing
(see intervention phase of Figure 9). Despite the fact that there are 100% overlapping
data points, you are thrilled with the results. You can see by examining the trend lines
that impressive differences exist between baseline and intervention phases. That is,
inappropriate vocalizations just kept becoming a bigger problem in baseline and they
consistently became less problematic in intervention.
A final challenge to visual data analysis relates to the length of time it takes for an
intervention to produce a desirable outcome. You will serve some students with ASD
who quickly respond to the intervention you select and others who will take time to
learn to change their behavior or develop their skills. The examples we have provided
thus far reflect typical data for students who respond quickly to an intervention.
Lets consider the example of Sami, a sixth-grade student with Aspergers Disorder.
She did not master multiplication and division of fractions during her fifth grade year so
her sixth-grade teacher decides to begin with these skills at the beginning of the school
year. Not surprisingly, Sami had not learned how to multiply or divide fractions over the
summer!
After collecting baseline data, Samis teacher puts a reinforcement system into
place and begins teaching her essential concepts related to multiplication and division
of fractions (see Figure 10). Over time, Sami begins developing these skills. Eventually,
there comes a point at which she really begins mastering these skills. Note that this
did not happen the moment her teacher put the intervention into place. The teacher
understood that Sami needed time to develop sufficient skills to show significant
improvements.
Because visual analysis can be very challenging, we recommend all school staff
should consult with a professional (e.g., behavioral analyst, psychologist, special education teacher, etc.) with expertise in single-subject research design. We explore this
research design in the following pages.
Figure 10}
Example of an Intervention that Requires Time Before

Change is Produced
Samis Math Worksheet
20
Baseline
Intervention
# of Correct Responses
18
16
14
12
10
8
6
4
2
0
1
10
11
12
13
14
15
School Days
Is the Intervention Effective?

In order to really know if a treatment is effective, you need to compare two or
more baseline conditions with two or more intervention conditions. A singlesubject research design allows comparison of an individuals response to an
intervention over time.
This research design is used by scientists, but it is often used by practitioners as
well. Practitioners like single-subject research design because it can be applied to one
individual. It can also be applied to a small group of students or an entire classroom
(although we do not cover these examples here).
One of the most commonly used single-subject designs is the reversal design. It is
also known as an ABAB design. Dont be intimidated by terms like research design.
These kinds of designs even occur naturally in our daily lives. We encourage you to harness the strength of this research design to answer the questions you have about your
students.
Reversal (ABAB) designs most often involve a baseline phase followed by an intervention phaseand then another baseline phase followed by an intervention phase.
This type of design demonstrates the relationship between the intervention and the
target behavior. Here is an example of ABAB research design from everyday life.
Have you ever dieted before? If so, it might have gone something like this:
A (Baseline): You decide you need to lose a few pounds.
B (Intervention): You go on a diet and drop a few pounds.
A (Baseline): You go off the dietonly to find a few months later that you have
gained a few pounds.
B (Intervention): You go on a diet and drop a few pounds!
Now lets apply this research design

to Caleb, a four-year-old with ASD who is
learning to play. You have decided to use
video modeling to teach Caleb new play
skills. You collect data in one baseline
and one intervention phase. You look at
the stability, trend, and overlapping data
points and conclude the intervention
is effective. Some people would rather
skip the second baseline and intervention phases and might wonder why they
would need to repeat them.
There is a very good reason. Often,
a number of environmental variables
change in the classroom at the same
time. Lets say a new student is introduced into the classroom and befriends
Caleb at the same time you begin the
video modeling intervention. If both of
those events occur at the same time,
how can you determine whether the
video modeling intervention is responsible for the behavior change? By using
an ABAB design, you can see a clear
relationship between the treatment and
the behavior.
With Caleb, you saw an improvement
in play skills during the video modeling
intervention phase. Although you would
like to see those play skills continue to
improve, you decide that you can take
a few days to re-introduce a baseline
phase. This will help you determine

whether the intervention is really effective. After graphing your data (see Figure
11), it becomes apparent that removing
the intervention has resulted in a substantial decrease in Calebs play skills.
You quickly re-introduce the intervention
and his play skills just as quickly begin
improving again.
You are now confident that you
should continue using the video modeling intervention.
You may think, But I already thought
the intervention was effective. Was it
really necessary to remove the intervention? We would argue that, in this case,
it was necessary. The data could have
just as easily shown that the intervention
was not the reason Calebs play skills
improved. Perhaps his new classmate
was showing Caleb how to play and his
skills were improving due to live modeling. If this was the case, spending all of
the time it takes to make videos is not
the best use of your time!
Although the reversal (or ABAB)
design is the most commonly used
single-subject research design, there
are actually many others that might
work better for your needs. Sometimes
you need to implement an intervention
with more than one student and you can use a multiple baseline across students
design. In this case, the intervention is staggered (i.e., introduced one at a time) across
students. If you need to implement an intervention for one student across numerous
settings, you can use a multiple baseline across settings design. In this case, the
intervention is staggered across different situations (e.g., classroom, then cafeteria,
then playground).
Identifying and providing sufficient descriptions of all research designs that might
be useful to you is beyond the scope of this manual. One book we have found that
clearly describes research designs as they apply to school settings is Applied Behavior
Analysis for Teachers (Alberto & Troutman, 2003). This book can be an excellent
resource to you in other ways as well (e.g., knowing how to develop the best operational definitions before starting to collect data, etc.).
Figure 11}
Graphical Representation of Calebs Play Skills Based on

Reversal Design
Calebs Play Skills
# of Appropriate Uses of Toys
Baseline
Intervention
Baseline
Intervention
7
6
5
4
3
2
1
0
1
School Days
10
11
12
13
14
Although single-subject designs and the various data collection methodologies are well-defined in the literature, use of these strategies requires
professional judgment during each phase.
For example, you must decide the following:
How long to continue baseline and treatment phases
The point at which your team has the capacity to implement the intervention accurately (see Chapter 5 on capacity building)
If environmental variables are influencing the stability of your data
Whether the intervention is effective (based on your visual analysis)
In a perfect world, student behavior would respond to all interventions in the
desired direction. In reality, professional judgment is essential when things dont go as
planned. So, what do you do when an intervention fails to produce the desired behavior change? While this can be frustrating and discouraging, there are problem-solving
steps that will help you assess the situation:
1. Be clear about definitions. Review the definition of the target behavior. It is not
uncommon to have an operational definition that does not reflect the actual targeted
behavior. This can result in inaccurate or misleading recording of dataespecially if
you have multiple data collectors (e.g., teacher, speech-language pathologist, paraprofessional, etc.).
2. Identify relevant variables. Determine if there are environmental variables
that could influence the daily recordings. If so, you may be able to gain control
over them, or at least predict when they will occur. It may be that you have to add
another research-supported treatment to your intervention on days when the environmental variable (e.g., lack of sleep) occurs.
3. Use available expertise. Be sure to draw on the expertise of all school professionals. Perhaps the speech-language pathologist determines that your target
behavior is not appropriate given the students communication delays. Similarly, the
psychologist or behavior specialist might help you identify the function or purpose
of challenging behavior. (A challenging behavior may function to gain attention, to
escape or avoid a person or activity, or to gain access to a preferred item or activity;
or the behavior may be automatically reinforced [e.g., self-stimulatory behaviors].)
The psychologist or behavior specialist could help identify the function(s) of the
behavior to develop more effective interventions.
4. Implement treatment accurately. You should ensure the intervention is implemented accurately. We all deviate from the way a treatment is supposed to be
implemented from time to time, and often we are unaware of the changes we have
put in place (see Chapter 5 on treatment fidelity).
Problem-solving strategies rely heavily on professional judgment. As mentioned
earlier, it is important to avoid using a cookbook method in treatment selection.
Problem solving through a difficult case is not just dropping the current intervention for
another intervention. It is case conceptualization with a critical eye. This requires your
training, your experience, and your professional judgment.
Cooper, J. O., Heron, T. E., & Heward, W. L. (2007).

Applied behavior analysis (2nd Ed.). Upper
Saddle River, NJ: Pearson Education, Inc.
Gulick, R. F., & Kitchen, T. P. (2007). Effective
instruction for children with autism. Erie,
PA: Dr. Gertrude A. Barber Educational
Institute, Inc.
References}
Alberto, P. A., & Troutman, A. C. (2003). Applied

behavior analysis for teachers. Upper
Cooper, J. O., Heron, T. E., & Heward, W. L. (2007).

Applied behavior analysis (2nd Ed.). Upper

2009).
Mithaug, D. K., & Mithaug, D. E. (2003). Effects

of teacher-directed versus student directed
instruction on self-management of young
children with disabilities. Journal of Applied
Behavior Analysis, 36(1), 133-136.
Carr, J. E., & Burkholder, E. O. (1998). Creating

single subject design graphs with Microsoft
Excel. Journal of Applied Behavior Analysis,
31, 245-251.
Cole, C. L. & Bambara, L. M. (1992). Issues
surrounding the use of self-management
interventions in the schools. School
Psychology Review, 21, 193-201.
Sulzer-Azaroff, B. (2008). Applying behavior

analysis across the autism spectrum: A field
guide for practitioners. Cambridge, MA:
Sloan Publishing.
Webber, J., & Scheuermann, B. (2008). Educating
students with autism: A quick start manual.
Austin, TX: Pro-Ed, Inc.
Incorporating Family
Preferences & Values Into
the Educational Process
As we noted in the introduction, federal legislation requires that schools use
research-supported interventions for students. Educational legislation also
supports the involvement of family members in the educational process.
Parents are experts on the strengths and needs of their children with Autism
Spectrum Disorders (ASD) (Danya International & Organization for Autism Research,
2004, p. 10). As such, parents should actively participate in decisions about their
childrens education. Parents should be involved both in their childs assessment and
in decisions that are made regarding service needs. In addition, parents and teachers
should collaborate when identifying skills to target for development (IDEIA, 2004).
Family choice is one of the most important components of a family-centered
approach. It recognizes the partnership of parents with school personnel and other
professionals in decision making (Murray et al., 2007). The family-centered model of
service delivery acknowledges that interventions and supports for children with disabilities are most successful when the familys concerns, priorities, and strengths are
considered (Peterson & Speer, 2000). Ask yourself, How often do I fully engage the
family in a discussion about the educational and treatment services I provide? and
How intently do I try to include the students perspective when developing treatment
targets or selecting interventions? Many of us can improve in these areas.
If we want to renew our efforts to apply a family-centered service delivery model for
students with ASD, we need to begin by understanding the unique challenges faced by
the families of children with ASD.
Here are a few points to consider:

Parenting stresses and social restrictions are common difficulties for families with a
child with ASD. Parents of children with disabilities say they experience challenges
in activities such as: enjoying family outings; going to other peoples homes; leaving their child with a babysitter; and shopping with the child (Cassidy, McConkey,
Truesdale-Kennedy, & Slevin, 2007).
Children with ASD are often involved with several different therapy activities that
take up a tremendous amount of the familys time. Maintaining this level of support for the child requires a great deal of time from parents, and often has financial
implications for a family as well (Kohler, 1999).
Many students with ASD take prescription medication or are on special diets, which
require additional resources from parents.
Parents may experience stress as they decide how to allocate their attention and
energy across family members. Parents may feel the strength of their marriage is
challenged or they may feel guilt about the limited time they spend with their other
children when so much of their attention is focused on the child with ASD.
Parents worry they lack sufficient information. They grapple with their childs disability, uncertainty about their childs future, and the physical and mental difficulties
associated with raising a child with a disability.
Considering these challenges, it seems clear that supporting a family member with
ASD can place heavy demands on the family and tax its physical, financial, and emotional resources.
The good news is that appropriate family supports can reduce these kinds of stressors. Appropriate supports enhance the well-being of both parents and children. When
schools use a family-centered approach and work to increase parental involvement,
not only do the parents and children benefit, but so do school personnel. For instance,
parents can provide information to help staff better understand their students.
Improved communication can also promote opportunities for generalization of skills
in settings outside of school (Davis-McFarland, 2008). Given the fact that generalization represents one of the greatest challenges to individuals on the autism spectrum,
the advantages of family-centered care are quite strong. In addition, students who
participate in the educational process are better prepared to participate in treatment
decisions in adulthood.
Supporting Family Involvement in

Evidence-based Practice
Encouraging parental involvement can include activities in the school, home,
and community. Examples of parental participation and student involvement
include activities such as:
Serving as a classroom volunteer. Parents can be involved in everything from
supervising during a field trip to collecting data in the classroom (see Chapter 3).
Maintaining frequent communication with teachers. School-home notes that

help everyone focus on the students increasing school successes can be useful.
Attending school-sponsored events. These can include things like support

groups or educational seminars. For instance, if a school autism program implements discrete trial instruction (DTI) as part of its educational model, parents often
receive education and training on DTI from school personnel. Training may be
followed by parents observing DTI with their child in the classroom, as well as frequent communication regarding the childs progress based on data collected during
DTI.
Incorporating learning activities into a students daily routines. This can

include tasks such as working on greeting skills at the grocery store or prior to
religious activities, identifying shapes and colors while driving, and encouraging
independence during the bedtime routine. Working collaboratively across settings
provides better supports to everyone and benefits the student the most.
Securing student input. Whenever possible, it is important to secure input from

students regarding their target behaviors and intervention options. Not all students
on the autism spectrum are capable of actively participating in the educational
process. But there is a danger in assuming all students are unable to help identify
educational and behavioral targets for improvement. Further, many students may
hold opinions about which interventions they prefer. If we can work collaboratively
with students in target identification and intervention selection, they are more likely
to actively participate in their own development throughout their lifetime. Leaving
students out of these processes is a lost opportunity for schools striving to help all
students reach higher levels of independence prior to graduation.
There are several factors a school must consider in order to effectively implement a
family-centered care approach. These include cultural variables, socioeconomic status,
family composition and availability, severity of symptoms, and school factors. Each of
these considerations can directly influence the level of parental involvement.
Cultural Variables
We can serve all students better when we improve our awareness of cultural variables. Certainly, having successful family-school collaboration requires an appreciation
of the views held by both groups. These views can be heavily influenced by the cultural
experiences of the parties involved.
Research suggests that cultural values often influence a persons views on disabilities. In order to best serve families from diverse cultural backgrounds then, educators
must be willing to learn about a familys customs, belief systems, communication
styles, and other factors that may impact parental involvement and their level of acceptance of various treatment options.
You can take several steps to increase the likelihood that research-supported treatments will be successful for learners from diverse backgrounds:
Take cultural values into consideration when the school team and the family select
treatment targets. For instance, many young students with ASD do not make eye
contact with the frequency of their peers or, when they do, the eye contact is fleeting. We often target eye contact in the course of educational services because {a}
it is a socially important skill for most individuals in our culture to develop, and {b} it
is often one of the first skills taught within the context of some research-supported
treatments (e.g., Comprehensive Behavioral Treatment for Young Children) in order
to improve responding. However, in some Native American and Asian American
cultures, avoidance of eye contact with adults is considered a sign of respect (Lian,
1996; Wilder et al., 2004).
Similarly, many of us would consider reduction of self-stimulation to be a critical
educational goal to target. Yet these behaviors are largely ignored by Navajo parents of children with disabilities, who tend to focus more on the strengths of their
children rather than behavioral excesses or deficits (Connors & Donnellan, 1998).
Consideration should be given to both cultural variables and educational implications

when developing treatment targets for students with ASD.
It is important to understand cultural variables, identify behaviors that actually need
to be targeted, and then work to develop an open and ongoing dialogue when differences in perspective emerge. For example, is the family comfortable with the
student having eye contact in a limited number of settings (e.g., when seated at a
table across from an educator in the school)? Can the school ignore self-stimulatory
behavior unless it interferes with teaching (e.g., when the child cannot divert his
attention away from self-stimulatory behavior to complete his work)?
Educators and service providers may need to be willing to modify teaching and
intervention strategies as appropriate to meet the needs of students with cultural
values and experiences different from the dominant culture. Consider the following
examples:
Lets say the teacher and paraprofessional use DTI as a means of teaching a
broad array of skills to a student with ASD. They may find it helpful to supplement
DTI with strategies such as {a} English as a Second Language (ESL) instruction from the childs school district (Winzer & Mazurek, 1998), {b} alternative
communication systems such as pictures (Snell & Brown, 2000), or {c} teaching materials in the most relevant language for the student (Baca & Cervantes,
1998).
Imagine that support staff have recommended the use of another researchsupported treatment, such as Schedules. Steps should be taken to ensure that
symbols and pictures are culturally meaningful for the child, as well as for persons with whom the child interacts in the home and school settings (Trembath,
Balandin, & Rossi, 2005).
Social development should be targeted for all individuals on the autism
spectrum. The school may have developed a Peer Training Package (another
research-supported treatment) to facilitate social skill development. When selecting peer models, efforts should be made to identify peers from similar cultural
backgrounds to that of the child with ASD (Wilder et al., 2004).
Like professionals in all other settings, school staff may have biases that can inadvertently enter the educational process. As with any treatment approach, educators
must examine their personal biases and expectations in relation to service delivery
for their students who come from a different cultural background than the dominant
culture (Wilder et al., 2004).
Biases may enter our interactions in the most unexpected ways. For example,
we may over-generalize information we learned in a course on multiculturalism!
Consider the issue of collectivism. Collectivism describes a particular outlook that
stresses the group over the individual, and interdependence of group members.
Some (but not all) cultures adhere to a collectivist perspective.
Several studies have indicated that people from the dominant culture assume that
collectivist aspects of certain cultures can lead to strong family support (Bailey et
al., 1999; Gatford, 2004). This may be true for some families, but it is certainly not
true for all.
In some cultural minority populations, having a child with a disability can be a source
of shame for a family. Also, cultural norms may discriminate against individuals with
disabilities, or can undermine the likelihood that parents will seek information about
disability issues. So, while knowledge of common cultural norms is helpful, school
professionals must keep in mind the individual needs of each family.
Socioeconomic Status
A familys socioeconomic status has been shown to have a significant impact on
parental involvement in education. Many low-income families report that they have limited access to information and professional supports for their childs disability (Baxter
& Kahn, 1999; Diamond & Kontos, 2004). This means the quality of total care may be
compromised and a childs progress may depend almost exclusively on supports he
receives through the school system.
Even when you try to establish a collaborative relationship with the family, financial
issues may present a problem. For example, families are often asked to make certain
their children practice skills at home. But some families do not have the necessary
financial resources to obtain the materials required for the learning activity.
Financial resources can also impact issues such as transportation. Schools should
consider a familys transportation needs when scheduling team meetings or other
school-based activities.
Employment and
Family Issues
Employment can impact financial
resources and the amount of time parents
have available for participating in the educational process (Brotherman & Goldstein,
1992).
For two-parent households, one parent
may stay home to coordinate the various
services that are required for the child with
ASD. A mother or father may also make the
decision to stay home because no childcare is
available for their child, or may become one of
the primary out-of-school therapists for the
child.
Complicating matters still further, it is not
unusual for parents to have more than one
child with some type of disability or educational need. In this case, the stressors are
increased as parents try to make certain each
of their children receives sufficient support.
The choice for one parent to stay home
can be a double-edged sword. Although it
resolves some issues, it may create others
(e.g., limited financial resources). Parents who
make the decision to stay home to address
service delivery concerns for their child with
ASD may bring unique expertise to the table
when you engage in evidence-based practice.
Military activity may temporarily affect
family composition. Military families who
are served in your school system may face
unique challenges. When military personnel

are sent overseas or are on duty at an undisclosed location, the entire family is missing
one parent. The child with ASD, his siblings,
and the remaining parent are all left with more
limited support under stressful conditions. In
addition, because military families are often
required to move frequently, the parent who
remains behind may lack a well-established
network of friends or extended family. Under
these conditions, it is even more necessary to
create an open line of communication and a
collaborative relationship between school and
home.
While involvement by extended family
members, such as grandparents, can be a
source of emotional and practical support,
it can also present significant challenges.
Parents may be pressured by relatives to
modify the intervention strategies used to
help the child with ASD. Some extended family members may deny the fact that the child
is on the autism spectrum, whereas others
impose their views about child rearing when
the family is already under severe stress.
These factors reinforce the need for and
usefulness of building a collaborative relationship between family and school. By working
together, the stressed family member may
be better prepared to address skills you have
taught in the school setting and generalize
them to the home and community.
Severity of Symptom
Presentation
Has a student on the autism spectrum
ever worn you down by the end of the day?
Imagine how challenging it is to care for
this child for all non-school hours of the day,
year-round. No matter how much parents love
their children, they, like all of us, have limited
energy.
Parental participation in the educational
process may be affected by a childs problem behaviors, and the severity of those
behaviors. Research has shown that maternal involvement in educational activities in
both home and school settings is related
to the severity of the childs behavior problems (Benson et al., 2008). In other words, a
mother whose child with ASD exhibits severe
behavior problems is more likely to identify
lack of time and limited energy as barriers to
participating in educational activities.
Severity of symptoms may also affect
how welcome parents feel in the school. It is
always difficult for parents to learn their child
is not successful in school. It is still more
challenging when parents find out their child
is disruptive or creates an unsafe environment
for himself, other students, or school staff.
Imagine how difficult it is to face this news
over and over again. Unless we work hard to
understand how tough this is for families, it
will be difficult to create an environment in
which they feel welcome to openly discuss
the need for specific intervention procedures.
Finally, the severity of a students symptoms has a significant effect on his ability to
participate in the educational process. Parents
of students who can participate in the selection of appropriate treatment targets and
interventions may be more hopeful about
their childs ability to manage his own affairs
in adulthood.
School Factors
It is important to note that school factors
can also influence family participation in the
educational process for children with ASD.
Consider the following:

School personnel often feel they are
unable to provide emotional support for
parents because of large caseloads and
ambiguity regarding their ability to provide
such support (Canary, 2008).
Many parents perceive school personnel
as authority figures, and are uncomfortable
voicing an opinion that may be in conflict
with the opinions of these individuals.
A mothers involvement in the education
of her child with ASD is affected most
by the attempts of school personnel to
encourage and provide opportunities for
active involvement in her childs education
(Seitsinger et al., 2007). What you do really
does make a difference!
School systems do not always involve
the student in the selection of appropriate treatment targets or interventions
designed to improve student skills.
Social Validity
Even a potentially effective treatment will not work for some families unless
they feel it is appropriate.
Social validity can be broadly defined as approval of or satisfaction with a specific
intervention. Social validity is usually evaluated by someone who works with, or shares
the life of, the student with ASD. Interestingly, social validity can influence whether or
not the treatments are being implemented accurately. It should come as no great surprise that parents who do not approve of an intervention are less likely to implement it
accurately in their home or community. You are less likely to meet your goal of a having
a child generalize a skill across settings if parents report low social validity.
For many years, only one factor was considered when researchers conducted
treatment studiesan objective measurement of the target behavior. This is understandable, but it falls short of what is necessary. We do need objective measurement
of whatever behavior we are targeting, but we also need to have data on social validity.
Although extensive literature has been devoted to identifying effective interventions
for students with ASD, few of these studies have examined the social validity of these
interventions. That is, there is limited information regarding parents perceptions of the
effectiveness of strategies that may be implemented in school settings.
A recent investigation (Callahan et al., 2008) examining the social validity of several
educational strategies (including individualized programming, data collection, researchsupported treatments, active collaboration, and a focus on long-term goals) yielded
some interesting outcomes to consider:
On a positive note, high parental social validity was reported for all the strategies,
with the highest ratings for strategies falling under the data collection category.
While still rated as socially valid treatments, research-supported treatments
received the lowest rating by parents. Several of the procedures included in this
category were interventions (e.g., modeling, prompting, DTI) that have been shown
to be effective based on the results of the National Standards Project.
Parents who had more training in these procedures were likely to rate them as
highly socially valid. This underscores the importance of having an ongoing dialogue
with parents about effective treatments.
Assessment of social validity should be extended to the student with ASD whenever feasible. Ask the student directly if she believes the treatment is leading to
improvements in her communication, social interactions, or independence in life skills.
Recommendations for Incorporating

Family Preferences and Values
People often think evidence-based practice is about the researchand it is!
But it is not about the research alone. The values and preferences of family members, including the individual with ASD when appropriate, must be
respectfully addressed. Otherwise, we are not engaging in evidence-based
practice.
Even if you have data to show that a current intervention results in improvements
for a student, it does not mean that your work is done. Your goal is also to create a
welcoming environment so parents can participate in their childs education. Further,
school staff must receive training to understand that, whenever feasible, the student
should participate in the educational process as well.
You already know that families are more likely to be involved in educational programming when it includes collaboration among parents and school personnel (Canary,
2008). You also understand the importance of using active strategies to incorporate
the values and preferences of families into the educational process for children with
ASD. Translating that knowledge and understanding into our daily activities, however,
requires effort.
Schools are most likely to engage in evidence-based practice if they have explicit
strategies for addressing family preferences and values. We offer recommendations
as a guide for schools in developing these strategies. These recommendations include:
data collection; ongoing communication; parent education and training; tackling barriers to family participation; informing families of their choices and options; addressing
conflicting views; establishing appropriate family supports; and supporting parents in
generalizing skills.
Data Collection
The first step in incorporating family preferences and values into the treatment process is ensuring that the educational team has a clear understanding of those values
and preferences. You should gather information on a familys motivation to participate
in their childs educational progress. You are already familiar with collecting data on
student outcomes (see Chapter 3), but data collection must be extended to the perspective of family members as well.
It is easy to misinterpret what it means when parents are not actively participating
in the education of their child with ASD. Some people assume that parents are satisfied with the supports their child receives. Others believe that parents are uninterested
in their childs educational progress. Yet it should be clear by now that there are barriers
that may impede parent participation in the process. You may find that you can increase
family participation by considering the barriers they face and offering supports to families (Davis-McFarland, 2008). Directly assessing the familys motivation to participate is
a great way to begin the process.
Dont restrict your information-gathering to the parents. Providing the student with
ASD the opportunity to voice his opinion about treatment goals or intervention options
is also important.
Several tools are available to assess factors that affect a familys

motivation to participate in the educational process:
The Family Needs Survey (Bailey & Simeonsson, 1990) can provide information
related to current stressors in the life of the family, and the need for support to manage those stressors (see Table 1).
Instruments such as the Child Preference Indicators (Moss, 2006) allow a family to
share personal knowledge and expertise about their child with the educational team.
This offers parents the opportunity to provide valuable input related to strategies for
reinforcement, self-calming skills, and other information needed for a successful
educational plan.
In order to gather information regarding parents specific needs related to the implementation of research-supported treatments, you may need additional tools. Hunter
and Wilczynski developed the Autism Spectrum DisordersParental Participation
Questionnaire (ASD-PPQ) for this purpose (see Table 2). You can use the ASD-PPQ
to gather information regarding parent knowledge and acceptability of research-supported treatments. It is important to gain insight into parents views regarding their
treatment options before you begin serving new students. For children who are
already receiving services, parents can complete this form prior to regularly scheduled meetings or other interactions.
Student participation in the educational process should occur whenever possible. It
can be helpful to identify the skills the student believes should be targeted as well
as her interest in learning about different research-supported treatments. Wilczynski
and Hunter developed the Autism Spectrum DisordersStudent Participation Questionnaire (ASD-SPQ) for this use (see Table 3). You can use the ASD-SPQ to gather
information from students who are capable of participating in educational decisions
that support their progress. Students who can complete this form are most likely
older students with stronger communication skills.
Please note: Comprehensive Behavioral Treatment for Young Children and Joint
Attention are not listed as interventions on this form. These interventions focus on
young children for whom the ASD-SPQ is not appropriate.
You should make it clear to the family that, should they decide to complete the survey, the information will be kept in strict confidence, and that their participation in this
kind of survey is purely voluntary.
Table 1}
Family Needs Survey
Table 2}
Autism Spectrum DisordersParental Participation Questionnaire

(ASD-PPQ)
Table 3}
Autism Spectrum DisordersStudent Participation Questionnaire

(ASD-SPQ)
Parent and student input is important, so gathering information is essential.

However, there are dangers in gathering this information if you do not use it in the
educational process. Here are several reasons why:
Families may believe you do not think their time is valuable. After all, it takes time to
complete these forms.
Families may feel alienated.
Families may be less likely to share relevant information with you in the future.
Ongoing Communication
Students transition in and out of school systems. School staff are most likely to
engage families when students first come in contact with schools. But continued
collaboration between the home and school is critical for long-term success. Families
should have frequent opportunities to share their opinions and concerns.
School staff need to create an open and ongoing dialogue with families. Parents
should be encouraged to share both their agreements and disagreements with the
educational team. This is the only way to be confident that family preferences and values are respected (Davis-McFarland, 2008).
School professionals are often so busy in their daily routines that they forget to
create such an open environment. There are, however, many opportunities to maintain
parent involvement in the educational process (see Table 4).
Parent Education and Training

Students are best supported when their educators and parents work together. Think
of the years of education and training you completed before serving students with
special needs. After that, you received ongoing training through the school system and
support from your colleagues. Still, most of us who provide services to children with
special needs will find ourselves uncertain about how best to proceed from time to
time.
Parents deserve the opportunity to receive training and ongoing support as well.
Parents who are knowledgeable about their childs disability are more likely to be
involved in their childs education, and are better able to extend the improvements you
Table 4}
Strategies for Maintaining Parent Involvement
Opportunities for
Maintaining Parent Involvement
Opportunities to Consider
Informal meetings
Parents may pick up their children for medical appointments

Parents may attend special class activities
(e.g., birthday parties)
Parents may be involved in sports activities
Formal meetings
IEP meetings
Parent-teacher conferences
Information sharing
School-home notes
E-mail or phone conversations
Volunteering
School outings
Fundraisers
Data collection in the classroom
Classroom assistants
School-based support groups
Autism support groups

Disability support groups
Advisory board
Capacity Development Team (see Chapter 5)

Parent-Teacher Association
Information-gathering forms
Family Stress Survey

Child Preference Indicators
Autism Spectrum DisordersParental Participation Questionnaire
Autism Spectrum DisordersStudent Participation Questionnaire
achieve with the student at school into the home or community. Thus, your students
successes may be maximized when parents receive sufficient education and training.
School staff can arrange for frequent training opportunities for interested parents
who are able to participate. These trainings can be formal or informal, led by teachers,
school-based therapy providers, school administrators, or outside consultants. In addition, educators can inform parents about independent training opportunities that may
be available to them (see Chapter 5 for additional recommendations).
Schools can set a regular schedule (e.g., once per month) to provide families with
frequent educational and training opportunities. Suggestions for training topics can be
gathered by reviewing parent responses to the Autism Spectrum DisordersParental
Participation Questionnaire. In addition, schools may wish to video or audiotape trainings so they can make them available for parents who are unable to attend.
Tackle Barriers to
Family Participation
As noted above, there are several factors
that affect the likelihood that families will be
involved in their childrens education. These
barriers should be identified and addressed
during the educational process.
information about the schools views in

advance, and avoid leaving families with
the impression that all decisions have
already been made.
Both parents and students can be overwhelmed by the jargon and acronyms that
professionals frequently use. Avoid the use
of educational jargon to the extent possible and, when unfamiliar terms are used,
ensure that attempts are made to explain
the meaning to families. Providing parents
and students with a short dictionary of
commonly used educational terms may be
helpful.
Consider these efforts toward

reducing barriers to parental
participation:
Finding the time to participate in the
educational process is often very difficult
for parents, particularly when the school
day is often shorter than their workday.
To counteract this challenge, schedule
educational meetings around times that
work for the family. Ask families to identify
what days/times work best for them (see
Parental Participation Questionnaire). Also,
give families plenty of notice for scheduled
meetings.
Provide parents with advance draft copies of materials that may be discussed in
meetings. For example, draft copies of
Individualized Education Plans (IEPs) can
be provided to the family for review as
early as possible.
Of course, it is imperative to explain to
the family that the materials they receive
are working documents that can be
modified in the meeting based on family or
professional input. You will want to share
When the primary language spoken in the

home is not English, you should develop
a plan to ensure clear communication
between school and home. For example,
consider providing an interpreter, offering
parent training in a language other than
English, and/or writing documents in the
familys primary language.
Transportation may be a challenge for
some families. For example, parents
may rely on public transportation, which
may influence their arrival time. Meeting
times may need to revolve around these
schedules. If families arrive well ahead of
a scheduled meeting, efforts should be
made to make them comfortable. Transportation may also affect which days parents
might be available. For example, a mother
or a father may have access to a family car
only one day of the week.
Parents may be concerned about their ability to find childcare for the student with
ASD, or their other children. School staff may need to arrange for childcare at the
school so parents can participate in meetings.
Unfortunately, students with ASD are often taught to passively respond to adults in
the environment. School personnel will need to encourage students to voice their
opinions about treatment goals and intervention options.
Inform Families of Choices and Options

Recognizing the family as the primary decision maker for a child is important. But
families will be active participants in the educational process only if you provide the
support they need to make informed decisions (Davis-McFarland, 2008).
You already know that school personnel are responsible for making parents aware of
educational options that are available for their child. But translating this knowledge into
practice is more challenging than many people realize. How often do we assume that
the parents have already seen and read their rights, so we hand them a written copy
without discussion? If parents in this situation dont understand their rights, they are
unlikely to admit it when surrounded by a group of professionals anxious to begin the
meeting.
We offer a brief list of issues and strategies that may empower families:
Encourage parents to ask questions. For example, when placement decisions are
made, provide parents with information regarding different placement options. They
may have questions about what these options mean for their child.
Will their child be pulled from the regular classroom? If so, for how long? How much
time will she spend in support services (e.g., speech-language therapy) each week?
What are the benefits and risks of the different types of service options available
to her? What social opportunities does she lose when she is in a more restrictive
environment?
Parents are likely to have many additional questions, but they may be too intimidated to raise them in the group. Despite the fact that it will extend the length of
these meetings, school staff should encourage parents to ask questions.
Invite parents to observe their children in the school. Often, students act very differently in home and school settings. This may be even more true for students on the
autism spectrum because they have difficulty generalizing skills from one setting to
another.
Sometimes educators and parents accuse each other of exaggerating or underestimating a childs skills. Very often, the difference in perspectives stems from true
differences in skill performance across home and school settings.
By inviting parents to observe their child in the classroom, at lunch, or on the playground, it becomes easier to have an open dialogue about the students skills and
needs in the school setting. Parents may have suggestions for handling challenging
behaviors that will benefit educators. Similarly, parents may be open to recommendations for generalizing a skill to home and community settings because they have
seen it as a real strength when observing in the school.
For parents who are interested, help establish communication with other families
who are facing similar challenges. Parents benefit from the opportunity to ask each
other questions and discuss their concerns. Parents can help each other understand
the options that are available to them both in and out of the school system.
Address Conflicting Views

Even when you have established strategies for obtaining parental input and created a welcoming environment that allows for open and ongoing dialogue, parents
and schools will not always be in agreement. Conflicting perspectives can be uncomfortable for all parties involved. This can create a challenging but not insurmountable
problem for the educational team and the family.
Consider the example in which a parent might identify an intervention for her child
that is in conflict with the educational approach suggested by school professionals. For
instance, a mother may request that her child be on a special diet while in school. Your
school system has reviewed the scientific literature on the diet and does not recommend the approach because harmful medical side effects (e.g., nutritional deficiencies,
loss of bone density) have sometimes been reported. How do you proceed?
In a situation like this, we would recommend moving forward together by

taking the following steps:
Show continued respect for parental expertise regarding a childs needs.
Effectively communicate your concerns for the childs health. Provide the family with
a copy of the Findings and Conclusions report so they can be familiar with current
research in this area.
Recommend that the family discuss medical aspects of the diet with a qualified
physician. It is important to collaborate not only across home and school, but also
with outside professionals.
Encourage a data-based approach for all treatments (see Chapter 3 on professional
judgment). Model the use of single-subject research design with other schoolrecommended treatments that are implemented. Show the parents how this can be
used to evaluate the effectiveness of the interventions the family puts in place (e.g.,
the diet). Provide support for parents who are interested in using single-subject
research design to identify the effectiveness of the intervention for their child.
In the end, as the primary caregivers for their children, parents have unique expertise related to their childrens strengths and needs. Their opinion should be carefully
considered and highly valued (McNaughton, 1994).
Establish Appropriate Family Supports

You can establish family supports within your building or district, and/or provide
families with information about supports that are available elsewhere. Some schools
establish parent support groups to offer additional support to families. These groups
create opportunities for families to share information and get to know other families in
similar positions.
If a school does not feel there is enough need to warrant a support group in their
building, collaborating with other schools in the district or providing parents with
information on community resources may be better options. Parents should not feel
pushed into participating in a support group, however. A sizeable number of parents
prefer privacy, have limited time, or feel that a support group would not be helpful.
Support Parents in Generalizing Skills

Given that children with ASD experience difficulties generalizing skills across
environments, it is essential to coordinate efforts to teach skills across multiple environments. Many learning opportunities naturally occur at home or when the family is
in the community. Parents can continue their involvement in their childs education by
engaging in activities at home. These can include child-directed play, creating opportunities for social interaction with other children, educational leisure activities such as trips
to a museum, and the development of adaptive skill goals such as toilet training, selfcare, and community safety skills (Benson et al., 2008).
Schools can facilitate skill development in the home and community by:
Providing materials that parents may need in order to work on specific skills
Providing parents with ideas and training related to skill development in naturally
occurring learning environments
Communicating with parents about a childs current goals and progress in her educational programming
Stressing your awareness of the importance of learning opportunities at home
(When possible, teachers or therapists can make home visits to demonstrate specific strategies for parents in the home.)
As noted earlier, a schools efforts to encourage parental involvement are
strongly related to the parents level of involvement in their childs education.
When school staff make clear efforts to contact parents and include them
in their childs education, parents report more positive experiences with the
school and are more likely to reach out to the school (Seitsinger et al., 2007).
Everyone on the educational team (e.g., teachers, specialty services, paraprofessionals, etc.) should learn how to create a welcoming environment in the school.
Administrative support is critical to creating school- and district-wide goals related to
parent involvement (Benson et al., 2008). School personnel will also need to consider
their own feelings related to parent participation in education, and address concerns
or biases as needed. Also, schools should develop training for school staff who are not
accustomed to the idea of a student fully participating in the educational process, if the
student has the capacity to participate.
When parents are knowledgeable about the needs of their children and receive
appropriate support from school personnel, the children perform better academically
(Seitsinger et al., 2007) and are likely to experience benefits in other areas of their
lives. Schools must take an active role in incorporating family preferences and values
into the educational process for children with ASD.
The following case example illustrates the importance of incorporating family preferences and values into the educational process. It also demonstrates the benefit of
gathering information related to family preferences and values prior to the implementation of interventions.
Case Example
Emma is a 6-year-old girl who will begin first
grade at a small elementary school in the
Northeast United States in the fall. She previously
attended kindergarten in a different district, and
her parents have moved over the summer due
to new employment for her father. The familycentered approach described below was initiated
prior to the first meeting of Emmas educational
team.
Emmas parents called the special education
director of the new school district, Dr. Smith,
to inform her of their move and Emmas special
education needs. Dr. Smith set up an informal,
face-to-face meeting with the family to introduce
herself and describe the process that the district
would undertake to develop an appropriate
educational program for Emma. During this meeting, Emmas parents expressed concern about her
previous placement, indicating that they believed
services were not intense enough to meet her
needs.
Emma has a complex developmental history and
currently has diagnoses of cerebral palsy, seizure
disorder, and autism. She is primarily nonverbal,
although she does produce some sounds and
says a few common words such as mama and
open. Her primary mode of communication is
sign language, and her mother is fluent in sign. In
her previous school, she received several support
services, including speech-language therapy,
occupational therapy, and learning support

services. Emma also had a paraprofessional who
was with her in the classroom throughout the
day. Her parents reported that her previous school
encouraged the use of an augmentative and
alternative communication device. However, they
noted they were unhappy with this suggestion,
given that Emma was already using sign language
to communicate. Further, the communication
device was cumbersome for her because of motor
difficulties with one side of her body related
to cerebral palsy. They also expressed concern
that she would become too dependent on her
paraprofessional.
Dr. Smith acknowledged their concerns, and
explained the districts family-centered approach.
She also discussed the concept of research-supported treatments. At the end of the meeting, Dr.
Smith asked Emmas parents to complete a family
stress survey, the Child Preference Indicators, and
the Parental Participation Questionnaire to gather
more information related to their values and preferences. (They did not ask Emma to complete the
Student Participation Questionnaire because it is
not developmentally appropriate for a 6-year-old.)
Dr. Smith gave the parents a stamped, selfaddressed envelope in which to return the forms.
In the meantime, she invited the family to observe
various educational options that may be available
to Emma, including a classroom for students with
autism, a regular education first grade classroom,

learning support services, speech-language
therapy, and occupational therapy. Dr. Smith gathered the necessary consent signatures from other
families to allow these observations to occur.
The responses of Emmas parents to the questionnaires revealed several sources of stress for the
family, with three children under the age of seven,
including one child with multiple disabilities.
Other stressors included their recent move to a
new home, beginning new jobs, and lack of family
support in the area. Other responses indicated an
interest in Comprehensive Behavioral Treatment
for Young Children and a number of other behavioral treatments. They also wished to increase
Emmas speech-language services to promote her
continued development of sounds and language
skills. Based on their observations in the school,
they cited the potential benefits of both the regular education classroom and the autism classroom
for Emma. They did, however, report concerns
about Emmas ability to interact with her sameage peers in the autism classroom.
The district conducted a comprehensive evaluation of Emma and used those results, along with
the information described above, to develop a
program for her. First, the autism support teacher
for the district visited Emmas family at home to
provide more information about the interventions
which interested Emmas parents. The teacher
also shared the data the school had collected to
show these treatments were being implemented

accurately by school personnel. With this additional information, Emmas parents were excited
about using these strategies with her.
Because the autism classroom utilized behavioral
treatments, the family expressed an interest in
having Emma spend a portion of her day there.
They were pleased to know their concerns had
been addressed when the school suggested
Emma should spend a portion of her day in the
regular education classroom; this would support
social skills development and provide opportunities for generalization of skills. However, both
the parents and the district were concerned that,
although the special education teacher and staff
were fluent in sign language, her regular education teacher was not. They decided to provide
an interpreter for Emma in the regular education
classroom to facilitate her ability to communicate
effectively.
The educational team then discussed the familys
need for additional speech-language services.
They authorized 30 minutes of speech-language
therapy for Emma four days a week. The family also received information about additional
speech-language providers in the area. Finally,
Emmas parents were invited to attend monthly
district-sponsored trainings on various issues
related to meeting the needs of children with
autism. They were also offered weekly updates on
Emmas progress toward educational goals.
This case example demonstrates the process school personnel can utilize to ensure
that family preferences and values are incorporated into the educational process.
Emmas parents reported high acceptability of her educational programming because
they were involved in decision making from the very beginning. They noted the willingness of Dr. Smith to meet with them personally and that of the autism support teacher
to come to their home. These supports eased their concerns and helped them to feel
valued. School staff also reported that a good relationship had been established with
Emmas family and were positive about her educational progress.
Callahan, K., Henson, R. K., & Cowan, A. K.

(2008). Social validation of evidence-based
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Cassidy, A., McConkey, R., Truesdale-Kennedy, M.,
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Seitsinger, A. M., Felner, R. D., Brand, S., & Burns,
A. (2008). A large-scale examination of
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Assessment, parental contact, and studentlevel impact. Journal of School Psychology,
46, 477-505.
Trembath, D., Balandin, S., & Rossi, C. (2005).
Cross-cultural practice and autism.
Journal of Intellectual and Developmental
Disabilities, 30, 240-242.
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Building & Sustaining

Capacity to Deliver
Treatments that Work
Throughout this manual, we have endeavored to provide youfront-line
interventionistswith the most current and accurate information available
on research-supported treatments for children and adolescents with Autism
Spectrum Disorders (ASD).
Each of the preceding chapters focused on the elements we identified as critical to
the development of evidence-based practice: the history and evolving understanding
of autism; the Established Treatments identified by the National Standards Project; the
importance of your professional judgment and data-based decision making; and the
need to incorporate the values and preferences of families in treatment plans. In this
final chapter, we discuss the need to build capacity for implementing effective interventions in the schools. We offer our strong recommendation to build capacity using a
comprehensive, systemic approach.
Let us be clear at the outset about one very important point. We understand the
real world situations and challenges you face, every day. We acknowledge your
commitment to excellence with the students you serve. This manual, and the recommendations herein, are meant to support the work you do and to further our mutual
goal of providing appropriate services by increasing evidence-based practice in the
schools. We know the implementation of evidence-based practice requires significant
time and resources. We also know that it will enable educators and schools to provide
more efficient and effective treatments, with better outcomes for your students with
ASD.
There are two approaches you may use to build the capacity to implement effective interventions for students with ASD. Specifically, you might adopt a grassroots
approach or a systemic approach to creating change.
The grassroots approach typically begins and ends with one professionals dedication to meeting the needs of an individual student. As is often the case, a teacher (or
speech-language pathologist, psychologist,

or other professional in the school) may try to
develop her own capacity to meet the needs
of one or more of her students. This grassroots approach places tremendous pressure
on individual service providers! Unfortunately,
we know that this approach to developing
capacity is the reality many educators face.
The grassroots approach has several inherent
weaknesses which will be familiar to front-line
interventionists and administrators.
Developing the capacity to offer treatments to one student at a time made more
sense when Autism Spectrum Disorders
were viewed as rare. After all, if most educators would never have the opportunity to
work with a student on the autism spectrum,
why build systemic capacity? In the 21st century, however, autism and its related disorders
are all too familiar in our classrooms. There
is no question that the number of diagnosed
cases of ASD has increased steadily for nearly
two decades (Hertz-Picciotto & Delwiche,
2009). Schools now must prepare all staff
to serve all children with ASDincluding
students with varying communication, social,
cognitive, and adaptive skills. The grassroots
approach is simply not an efficient strategy for
meeting the needs of this increasingly large
and diverse student population.
The complicated nature of treatment

decisions requires the participation and input
of all involved. As noted in Chapters 3 and
4, both initial treatment selection and the
decision to continue using an intervention
are complicated. When one person is solely
responsible for treatment selection and
continuation, decisions are more likely to be
based on incomplete and potentially erroneous information. A teacher may have heard
that a treatment was effective when, in fact, it
has no evidence of effectiveness. A principal
may invest training dollars in a workshop for
the entire staff based on the opinion of one
parent. This parent may report that the treatment worked for his son, but there may not
be evidence the treatment should be applied
to all students on the autism spectrum. It is
always best to make treatment selection and
continuation decisions in a systematic fashion
with input from all key stakeholders.
Another inherent weakness to the grassroots approach is that it does not address
the need for strategic planning. The accurate implementation of interventions often
requires time, energy, and fiscal support
beyond those immediately available to the
front-line interventionist. Marshalling such
resources requires strategic planning. This
plan may involve identifying barriers to
intervention implementation, preparing

training materials and treatment guides,
completing the groundwork necessary
for training to occur, and evaluating
essential outcomes. Strategic planning
and allocation of necessary resources
are best handled by a team that is dedicated to producing systemic change.
Therefore, we recommend that the
most efficient way to build capacity for
implementing effective interventions
for students with ASD is to take steps
that will produce systemic change. The
systemic approach addresses the needs
of the entire population of students with
ASD, and provides support to school
service providers as a team.
Development of a strategic plan for
building capacity takes time, as does
any endeavor requiring the participation
of a group. But it is time well spent. It
is only as a team of capable, competent
professionals that you can overcome
the barriers you will face. Once capacity
to implement effective interventions

has been developed, school professionalsworking in collaboration with
familieswill be in a far stronger position to quickly provide interventions that
have evidence of effectiveness (Adelman
& Taylor, 1997).
We present five key steps to

consider as you build sustainable
capacity in your school:
Step 1:
Establish the Planning Team
Step 2:
Problem Clarification and

Needs Assessment
Step 3:
Evaluating Outcomes
Step 4:
Developing a Training Plan
Step 5:
Sustainability
We will explore each of these steps

for producing systemic change in further
detail.
Producing Systemic Change

The autism spectrum is very broad, and includes students with a wide range
of skills and needs. These students are served in general and special education classrooms throughout the country.
Given the diversity in the ASD student population, school professionals will not
always feel adequately prepared to provide necessary supports to these students.
What strategies does your school system have in place to develop systemic capacity to
support these students?
As you assess your current capacity, you may begin by asking:

Have many school personnel attended the same workshops? If so, who made the
decision about securing training in this area?
Are school professionals in agreement about when and how interventions should be
implemented?
Is there a system in place to evaluate accuracy of implementation and assess the
outcomes for students?
Is there a sense among school professionals that new ASD treatments come and go
like fads?
Has there been an organized effort to ensure all school staff have access to necessary resources?
Who has planned to ensure this intervention can be sustained in the school?
The planning process will raise these questions, and many others. The first step is
to establish a well-functioning and representative team that is committed to increasing
the use of evidence-based practices.
This team holds many responsibilities including, but not restricted to, the
following:
Evaluating their current capacity
Determining how many different groups of students will be affected and how this
relates to capacity building
Identifying barriers that may undermine the plan (e.g., availability of resources, resistance from school personnel, lack of training, etc.)
Problem-solving collaborative strategies for reducing the impact of these barriers
(Although the process of reducing barriers can be time-consuming, it cannot be
rushed.)
Establishing the training process
Developing necessary resources
Advancing a plan to provide ongoing support to school staff
The remainder of this chapter describes a methodology for producing and sustaining the kind of systemic change that will build capacity to accurately implement
interventions.
Step 1: Establish the Planning Team
Never doubt that a small group of thoughtful, committed individuals can change the world. Indeed, its the
only thing that ever has.
Margaret Mead
In order to effectively produce system-wide changes, many people must contribute

to and feel ownership of the change process. A planning team should be developed
to begin preparation for systemic change. The diverse perspectives of planning team
members are a real advantage. The planning team will need to anticipate unique barriers to building capacity. Diverse experiences and perspectives will produce different
solutions to these challenges. In addition, all school staff will likely benefit from a
collaborative planning team that brings distinctive strengths to the table. Recognizing
the roles and responsibilities of various school staff members is the first step in the
process of capacity building, which is a continuing exercise in problem solving.
Each member of the planning team will bring specialized training and experiences
to the group. In addition to their training in specific content domains (e.g., teaching,
speech-language therapy, etc.), the most effective team will also include members with
process-specific skills.
These skills may include, but are not restricted to, the following areas:
Data collection. Data collection will be critical to the mission. So, at least one
team member should understand efficient and effective strategies for measuring change. Team members with experience in data collection will help determine
whether treatments are being implemented accurately and are leading to improved
outcomes for students.
Leadership. It can be beneficial to include team members with different leadership

skills. For example, one member might be skilled in fostering collaborative relationships, while another might help direct the team forward in the decision-making
process. Keep in mind that different leadership styles can lead to conflict if a collaborative and respectful environment is not regularly fostered by all team members.
Generalization. At least one team member should be charged with ensuring the
plan to build capacity is extended across relevant environments (e.g., hallways,
playground, cafeteria, etc.). Ideally, this staff member will have experience providing
services across multiple environments.
While there will be a natural division of responsibilities on the team, it is important
from the outset for everyone to have a shared sense of commitment to the process
and responsibility for a successful result.
The two main functions of the team are planning and evaluation. The steps required
for planning for capacity building are laid out in detail in this chapter; evaluating outcomes is also addressed.
Your planning team should represent all of the professionals who will deliver the
treatment. In addition, the team should include representatives of any group that is
responsible for ensuring the treatment is implemented accurately and sustained over
time. This will include instructional agents as well as support services, personnel development, and administrative services staff.
Each of these groups is discussed below.
Instructional Agents
Individuals who regularly provide educational services to students with autism
should be well-represented on the school-wide planning team.
Keep the following points in mind as you develop your team:

There are benefits to including paraprofessionals as well as teachers. Paraprofessionals often spend a good deal of instructional time with the student with ASD.
As front-line interventionists, they may also provide unique insight about barriers
to capacity building.
At least one instructional agent on the team must have expertise in how to
modify curricular materials if new treatments are implemented.
Another instructional agent must be able to determine how the new treatment
will impact existing goals. For example, how will the new treatment relate to
academic, behavioral, and social goals?
Support Services Staff

In addition to instructional agents, support services are often necessary for individuals on the autism spectrum. Support services personnel often play a crucial role
in helping students meet their Individualized Educational Plan (IEP) goals.
The following professionals may offer

valuable perspectives to the team:
Behavior analysts, counselors, and psychologists. Behavioral or mental health
support is often necessary for students

with ASD. In addition to the behavior
problems (e.g., self-injury, aggression)
that some children on the autism spectrum demonstrate, issues of depression
or anxiety may present a significant
impediment to successful life and school
functioning for older students on the
spectrum. These professionals often have
training on how to increase developmentally appropriate skills as well.
Physical therapists. Students with ASD

may require physical therapy if they have
motoric limitations that interfere with
their ability to functional effectively in
their environments. Their targets may
include improvements in motor skills, balance, and coordination.
Occupational therapists. Occupational

therapy may be necessary to help
students on the autism spectrum participate fully in school-related activities.
Treatments may need to be adapted so
that these students will be more likely to
make gains and progress in their treatment objectives.
Speech and Language therapists. Most

individuals with ASD experience some difficulties with communication. As noted in
Chapter 1, these difficulties may include
deficits in verbal and nonverbal communication. Even when students on the
autism spectrum do not have measurable
deficits in receptive or expressive skills
early in life, social pragmatic skills are
often impaired and become an obstacle
to success for children.
Transportation professionals. Like their

typically developing peers, many students
with ASD receive transportation services
from their school system. Some of these
students will require intervention plans for
the transportation process. For example,
students on the autism spectrum often
have severe social challenges. Waiting
with other children to board the bus, or
riding the bus, may present difficulties for
these students. Sometimes, a student
with ASD is bullied or victimized in some
way. Behavioral issues may also present
challenges during transportation. In all of
these instances, staff need to be trained
and supervised in the use of approved
management strategies consistent with
those provided in other educational
environments. A bus driver may be able
to provide critical input on whether or
not a student with ASD or his peers are
responding to treatment.
Family resource specialists. These specialists work with the families of students with ASD to make them aware of services available in the school system,
including after-school services. They often help families connect with additional
services available in their communities. Support services for family members
contribute to effective and durable treatment outcomes. These services offer
much-needed respite and help ensure that families have the stamina and
resources necessary to meet treatment goals in the home and community.
Family resource specialists can also facilitate the family involvement described in
Chapter 4.
Youth service specialists. Some school systems have a wide variety of youth
services available. These may include tutoring programs, recreational services, or
health services programs.
Personnel Development Staff

These individuals are dedicated to developing capacity to meet the schools
goals by providing training to school professionals. They offer a range of services,
including pre-service trainings, in-service trainings, direct trainings, and post-training
follow-ups. Because these professionals often have significant expertise in developing capacity in schools, its important to include this group in the planning team
process.
Administrative Services Staff

Of course, administrators are essential to developing systemic change. Most
people widely recognize the role of the administrator in securing necessary
resources. However, the role of the administrator should extend far beyond issues
of resource allocation.
The planning team must address a broad range of issues; it is important for
administrators to understand what is required to produce systemic changes, and
why. This will be essential as they implement a plan to develop and sustain capacity.
School administrators have more experience in managing systemic changes than
any other school professionals. Their unique insight will likely ground the planning
team so that real change can occur.
Administrators are accountable forand should be involved inevaluating

whether the efforts to produce systemic change in evidence-based practice actually
lead to improved outcomes for students with ASD. Administrators, along with all
other members of the planning team, must be familiar with the treatments that are
selected, the steps that must be completed in order to build capacity to implement
those interventions, the key components of determining if the treatment is being
accurately implemented, and the methods for evaluating whether a treatment is
producing favorable outcomes.
Step 2: Problem Clarification and Needs

Assessment
There are momentswhen it is incumbent upon

those known for their wisdom and clarity of vision to
survey the problem, with all its complexitiesin a
bold drive toward new horizons.
Anwar Sadat
Problem Clarification
Once the planning team is in place, its work begins with problem clarification.
The team must clarify the exact nature of the problem it faces as a system. It does
so by moving through the three components of problem clarification:
1. Current capacity evaluation: Determine the extent to which the school currently
has sufficient capacity to implement effective interventions
2. Problem definition: Describe the nature and the scope of the problem
3. Systemic identification: Identify which systems will be affected by their efforts
to produce systemic change
Lets consider each of these components in more detail.
Current Capacity Evaluation

When you transition from a grassroots approach to a systemic approach,
your planning team will need to evaluate
each member of the school staff who
serves students with ASD. Its important
to understand the perceived knowledge,
skills, and treatment integrity (i.e., extent
to which an intervention or interventions
are being accurately implemented) of
each of these staff. We developed the
Research-Supported TreatmentsTeacher
Report Form (RST-TRF) to help you collect
this information from staff members (see
Table 1).
Keep in mind that self-reporting may
not accurately identify the exact level of
knowledge, skill, or treatment integrity
for research-supported treatments in the
school. Service providers in all agencies
may sometimes incorrectly believe that
they {a} know the essential components
of an intervention or {b} accurately implement these interventions. Despite this
fact, the RST-TRF can be useful; it can
help you identify perceived strengths or
weaknesses in your schools capacity. The
RST-TRF can also help identify essential
resources for developing system-wide
capacity (e.g., candidates who may serve
as a master teacher or consultant). If
school staff consistently report that they
lack knowledge about research-supported
treatments, you have identified deficits
that must be addressed.
The RST-TRF is helpful for school

systems that use a grassroots approach
to building capacity. It may also be helpful
when a school has adopted what we call
a train-and-hope strategy to systemic
capacity building. Consider the following example. A school wants to build
capacity among its staff. As part of its
plan, it sends a few school personnel to a
two-day workshop. The goal is for these
staff members to become experts on the
intervention; they can then serve as consultants to other school staff. So, these
staff members were trained, and then
everyone hoped the schools capacity
would improve. Unfortunately, capacity
building often requires more than attendance at a workshop. You must ensure
that staff who are given the responsibility
to implement an intervention (or to teach
others to accurately provide treatment
services) actually have the capacity to do
so. The RST-TRF can help identify areas
where past or current training resources
are insufficient to produce appropriate
levels of mastery of treatments.
If your school system has already
adopted a systemic approach like the one
described in the rest of this chapter, you
already have a clear understanding of the
schools capacity to implement selected
interventions. The RST-TRF may still be
beneficial to secure input from new staff
entering the system, or to monitor staff
self-assessments on a regular basis.
Table 1}
Research-Supported Treatments Teacher Report Form (RST-TRF)
Problem Definition
Your planning team was convened to increase the schools capacity to use
research-supported treatments. Now, the team must clearly define the nature
and scope of the task ahead.
Consider these questions as you explore how to identify which treatments to

develop:
1. Do you plan to develop school-wide capacity to provide many or all of the
research-supported treatments? Eleven Established Treatments have been
identified (see Chapter 2). Developing capacity to implement many or all of
these interventions is a major commitment for educational systems. It will
require a detailed plan for its implementation, and may take an extensive
period of time to complete.
2. Will you build capacity in more than one area simultaneously, or sequentially?
If you build capacity simultaneously, are there sufficient resources to develop
the capacity to implement all the interventions with a high degree of accuracy? If you build capacity sequentially, can the needs of the students with
ASD be adequately addressed while you await the second, third, or fourth
intervention?
3. Will different school professionals develop capacity with two or more
research-supported treatments? If so, will they be expected to serve as consultants or master teachers for other school staff? What supports are in place
to encourage their development as trainer-of-trainers?
Another important consideration in capacity building involves whom you
serve. Which populations will you target with the selected treatments?
Should the treatment be targeted for all students with ASD?
Should the treatment be targeted for students of a particular age?
Should the treatment be targeted for students with specific skill deficits?
Should the treatment be targeted for students with behavioral excesses?
Should the treatment be targeted for students with specific diagnoses?
Are there any additional variables that might influence the scale on which
these treatments might be applied?
Trainer of Trainers
Master teachers or consultants often follow a
and able to provide constructive feedback that
training-of-trainers (TOT) model. The TOT model
promotes a positive learning experience.
involves building capacity through training and

technical assistance. A trainer fosters a collaborative learning environment. The trainer must be able
to prepare training materials, deliver instruction,
and provide follow-up sessions (e.g., coaching and
booster sessions) to support the teachers generalization of knowledge and skills to the students he
serves.
Training extends beyond lecture to structured
The TOT model is often applied in educational

settings. Trainers often have knowledge and skills
regarding the implementation of an effective
intervention prior to their interest in serving in
this role. However, knowledge and skills are not
enough. Trainers must themselves receive sufficient training to develop appropriate materials,
teaching activities, and strategies for fostering a
collaborative teaching environment.
experiential learning (e.g., role-plays, direct delivery

of instruction with individualized supports from the
trainer, etc.). The trainer must be culturally sensitive
Many interventions can be applied with the vast majority of students on the
autism spectrum. However, you may need to use your professional judgment
along with the information provided in the Findings and Conclusions report to
identify the best strategy for building capacity in your school. For example, you
may know that joint attention skills are often targeted with the youngest students with ASD. Your planning team may make the decision to develop capacity
to implement joint attention skills for preschool teachers and support staff. In
contrast, intervention strategies included in the Behavioral Package treatment
category have been successfully applied to students of all different age groups.
Your planning team may determine that all educators in the school should have
the capacity to implement Behavioral Package treatment strategies.
System Identification
After the team evaluates current capacity and clearly defines the problem, it
must determine which systems will be involved in the treatment. For example,
the team must identify which instructional services, support services, personnel
development, or administrators will be most affected by the decision to increase
capacity. You began this process when you established your team. But you must
re-examine this issue because not all of the individuals most affected on a daily
basis will be represented on the planning team. Strategies for securing input
and developing collaboration between the planning team and the professionals
on the front line are essential. This is why a needs assessment is a necessary
process.
Needs Assessment
Before beginning formal staff training, its important for your planning team to
conduct a needs assessment. This will identify barriers to implementing the treatments you have identified. A needs assessment allows the team to systematically
assess the school staffs perceived needs and barriers. A needs assessment can be
completed through a survey or interviews. In the end, it should provide an indicator of what will be required to move the school forward toward an evidence-based
approach to practice.
The needs assessment helps front-line interventionists provide critical input

into the capacity-building process. Without getting buy-in from a broad range of
front-line interventionists, it will be difficult to produce meaningful long-term change
(Sims & Sims, 2004).
Following is a review of possible barriers to consider as your planning team
completes a needs assessment. Although the purpose of the needs assessment
is restricted to evaluating current perspectives, we have also offered strategies for
reducing these barriers.
Barrier 1: Differences between the existing and proposed interventions.

Barriers to treatment implementation are more likely when a greater discrepancy
exists between the treatment being utilized and the treatment being adopted.
Most of us are more likely to complete training and then implement an intervention with a high degree of accuracy if the effort required is minimal. We should
expect the same to be true for all front-line interventionists. The planning team
should evaluate the degree of change required with any new treatment, and
then identify meaningful ways to acknowledge or reward the increased demands
placed on school staff.
For example, consider the difference between using Schedules and simple
Self-management systems. Both involve {a} breaking a task into component
parts, {b} having students indicate when a task component has been completed,
and {c} delivering reinforcers at the conclusion of the task. The two treatments
differ in that the student monitors his own progress and self-reinforces when
Self-management is used. Given how minor the difference is between these
treatments, school staff already using schedules are not likely to resist adding
Self-management to their repertoire of Established Treatments.
But now consider how different Peer Training is from Schedules. Peer Training
requires identifying socially skilled peers and then teaching them to facilitate
social and play interactions with a child with ASD. In addition to implementing
a teaching protocol with the typically developing peers, this process requires
ongoing monitoring of both the peers and the student with ASD. In this case, it
is likely that school staff will be more resistant to adding a treatment like Peer
Training, given how different this process is from their previous experience with
Schedules.
Barrier 2: Additional time required to implement new treatments. We all feel that
we have too much to do and too little time to do it. The needs assessment must
consider how training and implementation requirements will add to an educators time demands. Ignoring this reality can undermine plans to introduce new
interventions.
Consider the following factors that may influence resistance from school
staff:
Who would be involved in implementing the intervention? What training
would they require? Remember, the amount of training necessary will be
related to the amount of previous experience staff members have in implementing a given treatment. It will obviously take longer to train staff with less
experience.
Training often involves a didactic component, an experiential component, and
sustained coaching from a consultant or master teacher. School staff are more
likely to be resistant if they are expected to complete all their regular activities while receiving this training. The planning team may need to develop a
strategy for addressing the staffing needed to manage everyday tasks while
all components of training are delivered.
What would be involved in preparing the materials? Preparation of materials
may be very time-consuming. Materials may involve pictures, objects, worksheets, checklists, or any other stimuli used to teach students. If the school
develops multiple sets of materials that are readily available to all educators
involved in implementing a new treatment, it will require less time for the
front-line interventionist, and will likely reduce resistance.
The planning team may also need to consider what modifications to materials
may be necessary for students with additional disabilities (e.g., cerebral palsy)
or co-morbid conditions (e.g., pica, the ingestion of inedible objects). Staff
may also need to evaluate materials for developmental appropriateness (e.g.,
the toys used in Peer Training may be very different in a preschool classroom
than in a second grade classroom). Note that you may not be able to anticipate all modifications. Establishing a consultation team can help front-line
interventionists address modifications of materials on an ongoing basis.
Transportability and replaceability (how easy it is to replace materials) are
two more issues to consider when materials are prepared. Materials may
need to be transported across settings within the school system, or across

home and school environments. The planning team should anticipate that
materials may be lost or destroyed when they are transported. More than
one copy of materials will be necessary because {a} more than one staff
member may need to use the same materials and {b} materials may be lost or
destroyed.
Barrier 3: Treatment acceptability. It is important to know if front-line interventionists find a new treatment acceptable. If a staff person doesnt approve of a
new treatment, how likely will she be to implement it accurately? When making
plans to produce systemic changes, it is best to evaluate the acceptability of a
new treatment for all individuals who will be implementing it.
There are several tools you can use to assess treatment acceptability. For example, the Intervention Rating Profile15 is a 15-item questionnaire designed to
evaluate the acceptability of treatments in school settings (Martens, Witt, Elliott,
& Darveaux, 1985). Each item is rated on a six-point scale ranging from strongly
disagree to strongly agree. Scores above 52.5 indicate a treatment is acceptable. A variety of treatment acceptability measures have been developed (Carter,
2007) and schools may elect to use one or more of these tools based on teacher
preference for these instruments.
There are several reasons a treatment might be considered unacceptable. For
example, some treatments may be considered unacceptable on ethical grounds
or because they are inconsistent with school policy. However, treatments are
sometimes deemed unacceptable based on insufficient or inaccurate information. You can address resistance related to treatment acceptability by ensuring
that front-line interventionists have an accurate understanding of the essential
components of any intervention they may be expected to implement. Remember
that it is important to openly discuss all treatment acceptability concerns.
Barrier 4: History of treatment delivery. School staff may have a natural resistance to new treatments based on their history of delivering interventions. First,
school staff may already have a commitment to the interventions they currently
implement. Second, front-line interventionists may be skeptical if novel treatment approaches have been adopted in the past (without sufficient support) and
then discarded. More discussion follows on these two reasons for resistance.
Effort as a Barrier
Change is hard! Changing from an existing treat-
You may be able to reduce resistance if you initiate
ment to a new treatment always requires more
a motivational system for school staff who are
effort than sticking with what is already in place.
developing new skills. This may involve a formal
We first need to assess how much effort will be
recognition of the sustained effort front-line inter-
required to change from the current educational
ventionists are investing, or something as simple as
practices to the new treatment.
informally mentioning your respect for an individual
It takes time to become proficient at implement-
educators efforts.
ing a new intervention, and it taps into your

energy reserves as you become an expert. Until
they become proficient, front-line interventionists will feel fatigued from the additional effort
required to put a new intervention in place. The
planning team may need to estimate the length
of time it takes for the average staff member
to become proficient at implementing the new
intervention.
Commitment to current interventions

School professionals often have specialized training for the children they
serve. Some professionals may be trained in specific educational techniques
during their formal coursework and later continue their education through
additional coursework or training seminars.
When front-line interventionists have extensive training in a treatment that
has evidence of effectiveness, it works to the schools advantage. Why would
they resist further use of this treatment? But what happens when previous
training involves a treatment that does not have research support?
Front-line interventionists tend to believe in the treatments they have been
trained to usewhether or not there is any evidence of effectiveness. This
may be particularly true when the treatment has been used in the past and
the educator had a sense that it was effective. This is one of the reasons
data collection is so important (see Chapter 3). If high-quality data have not
been collected, we have only our beliefs on which to base our decisions.
We are all inclined to believe that our efforts produce favorable outcomes.
We should not be surprised, then, when we find resistance among front-line
interventionists.
Our history in using specific techniques makes us more biased against
alternativeseven when there is evidence the treatment is truly effective. In
order to convince someone that he should switch from a current educational
practice to a new Established Treatment, you must provide clear and compelling evidence. We hope the Findings and Conclusions report of the National
Standards Project in the Appendix of this manual assists you with this task.
Skepticism
Some professionals are resistant to change because they have been through
this before. Unfortunately, many school professionals have seen numerous
treatments become popular and then fade away during their tenure. Its hard
to be convinced that you should modify the educational services you are comfortable providing if you think the new treatment is a fad. This is one reason
to avoid fads altogether. But it is an entirely different matter when Established
Treatments are identified as the goal of systemic change. There are now
evidence-based practice guidelines like those in the Findings and Conclusions
report that can help you determine which treatments should be a primary
focus of systemic change.
The Findings and Conclusions report may not be enough to address
entrenched resistance based on skepticism. In this case, staff may become
motivated to use Established Treatments (i.e., those that are demonstrated
to be effective) to avoid naturally occurring negative outcomes. For example,
what school professional is not motivated to avoid a due process hearing?
School professionals who do not use Established Treatments will be more
likely to find themselves in the uncomfortable situation of trying to defend the
use of alternate treatments. Although most school professionals will be motivated to increase their capacity to implement effective interventions in order
to improve student outcomes, we recognize that nearly everyone is motivated
to avoid a legal dispute.
Further, engaging in evidence-based practice is now legally mandated and
a part of the ethical and training guidelines for many professionals. The No
Child Left Behind Act (2001) includes over 100 references to using educational
services that are based on scientific research. The Individuals with Disabilities
Education Improvement Act (2004) also states that instructional practices
should be scientifically supported. In addition, ethical guidelines like those
put out by the National Association of School Psychologists (NASP) or training guidelines like those developed by the Network of Autism Training and
Technical Assistance Programs (NATTAP) may also influence staff willingness
to embrace the changes required to engage in evidence-based practice for
students on the autism spectrum.
Barrier 5: Organizational Climate. Organizational climate refers to the atmosphere within the school system. Is there an open and ongoing dialogue among
professionals representing different service systems in the school? We know
that many different systems will be affected by systemic changeare these
systems really ready to change?
Convening the planning team is the first step in building capacity. But the
team alone does not guarantee the systemic change you will need to engage
in evidence-based practice for students with ASD. If the meeting of the newly
established planning team is the first time a diverse group of professionals has
come together to produce change in the school, you should expect that the planning stage will take some time.
If the tone of the school system is one of open dialogue, the needs assessment
is likely to result in accurate information that your planning team can act on. On
the other hand, if the school system is closed to change, school professionals
may not feel as comfortable acknowledging their limitations. In addition, your
planning team will probably have a more difficult time working together effectively to address the barriers to treatment implementation identified during the
needs assessment.
How do school professionals respond to the needs assessment? Does it spur
conversation among individuals outside the planning team? Are the planning
team members motivated to address the concerns and needs of their colleagues?
Cultivating an open organizational climate often begins with the administrators.
It is nearly impossible to create a more open organizational climate if administrators do not seek feedback from the bottom up, or if they are not open to
suggestions for improving educational services. When administrators actively
participate on the planning team, they send a clear messageadministration is
interested in the concerns raised by front-line interventionists.
However, the responsibility for an open system does not lie exclusively with
administrators. All school professionals contribute to a sense of openness or
closeness. There is an entire field of study devoted to modifying organizational
climates. Although we cannot do justice to the topic here, we can make a few
recommendations for improving the organizational climate of a school system
that is not yet sufficiently open to the idea of change.
Moving organizational climate toward acceptance of systemic change begins
with the planning team. Take the time to assess the value that each planning
team member places on transitioning from existing educational services to
research-supported treatments. The team must be able to openly discuss resistance to change and work collaboratively to problem-solve strategies before it
can address barriers outside the group.
We have already identified a number of reasons why school professionals
may be resistant to making systemic changes to their schools. You can begin
improving the organizational climate by

acknowledging that these reasons {a}
are often very legitimate and {b} may be
motivated by a desire to provide the best
educational services available (e.g., a
teacher who is concerned that teaching
a self-management system to a student
will take time away from teaching that
student other new skills). Without recognizing the very real challenges school
professionals face in their efforts to
improve services for their students, you
will not be able to have an open dialogue
about how to develop a sustainable plan.
In addition to encouraging open dialogue
about the potential barriers to implementing Established Treatments, and
developing solutions to those barriers,
there are a number of other ways to
improve the organizational climate. So
many school professionals are truly dedicated to helping their students reach their
greatest potential. However, even the
most committed educators can become
worn down by daily demands. You may
sometimes need to remind one another
why you entered this profession. You
can often reduce barriers to producing
systemic change by simply asking each
other to remember that you will improve
student outcomes by using treatments
that have evidence of effectiveness.
Finally, think of the entire school staff
as a team. This will allow you to adopt
strategies that promote effective teambuilding.
According to Webber and

Scheuermann (2008), the following
strategies encourage effective
communication:
Listen well.
Speak in a lively way, fluently, and
with confidence.
Use the language of feelings and positive one-liners.
Use self-disclosure to help build
relationships and keep communication
lines open.
Interpret behavior and use body language to enhance your message.
Express open-mindedness.
Give constructive feedback.
Genuinely reinforce people when they
do what you asked.
Webber and Scheuermann (2008)

also advise against the following
communication strategies:
Being overly punitive
Displays of impatience
Expression of over-concern
Arguing
Ridiculing or belittling
Making false promises
Rejecting the individual
Step 3: Evaluating Outcomes
If you can not measure it, you can not improve it.
Lord Kelvin
Before the planning team develops a training plan, you should establish your
intended goals. Why are you developing the capacity to implement the new
Established Treatment? This process should involve evaluating changes for students
and for the entire school organization.
Evaluating Outcomes for Students

The reason to go through all the effort of producing systemic changes is to
help students reach their potential. The planning team members should develop a
process for evaluating whether student outcomes actually improve as a result of
implementing the new treatments. Strategies for evaluating student outcomes are
covered in depth in Chapter 3. Here we will merely point out that measuring change
requires operationally defining your intended outcomes. The target goals should
be defined in a specific, observable, and measurable form. In addition, systematic
application of single-subject research design will be necessary to determine if the
intervention is effective with given students.
These strategies can be used to determine if a given student improves once an
intervention has been put into place. In addition to building systemic capacity for
implementing effective interventions, the planning team should develop systemic
capacity for evaluating student outcomes. Student outcomes must be measured
individually, and decisions about treatment continuation or modification should be
made on a case-by-case basis. However, the planning team should aggregate the
results across students to determine if an intervention is producing improvements
for students with ASD throughout the school.
When student outcomes are not favorable, one of the first questions you should
ask is, Are these interventions being implemented with a high degree of accuracy? This question is explored below.
Evaluating Outcomes for the School Organization

One of the reasons you implement system-wide changes is to enable educators to provide Established Treatments with a high degree of procedural accuracy.
Procedural accuracy is also known as treatment integrity, treatment fidelity, or procedural fidelity. No matter what term you use, the goal is to determine the extent to
which you are correctly implementing an intervention. There are several reasons to
assess procedural accuracy.
First, if school staff deviate from the way an intervention is supposed to be
implemented, they are no longer using the agreed-upon treatment. Professionals
sometimes feel they should modify a treatment based on what is convenient, what
seems reasonable given the available resources, or for a variety of other reasons.
Its helpful to ask ourselves, Would I feel comfortable if my healthcare
provider modified a necessary medical procedure based on convenience or availability of resources? Most of us would not feel comfortable with the healthcare
system adjusting the dialysis machine or the chemical composition of chemotherapy treatments for the reasons stated above. Similarly, most parents dont
feel very comfortable if educators make a decision to modify an Established
Treatmenteven if the motivations are pure.
Second, the school made the decision to build capacity for implementing
research-supported treatments for a reasonthere is evidence that they work!
Is there any evidence that the modified strategy works just as well? If not, it
is generally best not to make modifications to the treatment. This is not to say
that modification can never be considered. Should modifications to a treatment
be needed, consider the suggestions in Accommodations in the upcoming
Sustainability section.
Developing Guidelines/
Manuals
Some Established Treatments have
treatment guidelines or manuals commercially
These guidelines or manuals should clearly
available; others do not. The planning team must
outline the materials needed to implement
develop treatment guidelines or manuals that
the intervention. They should also identify
provide instruction to all of the professionals in the
the roles and responsibilities of all front-line
school system on how to deliver the treatment.
interventionists.
Treatment guidelines or manuals should clearly
As noted previously, educators should make
explain the procedures that will be used, and they
every effort to implement an intervention exactly
should do so in accessible terms. Procedures
as it was put into practice in the studies that
should be broken down into component parts so
support its use. However, we have also acknowl-
that {a} educators can implement the intervention
edged that individual modification may be
and {b} another school professional can assess
necessary on rare occasions. You should antici-
the extent to which the procedures are being
pate permissible modifications of the procedures
accurately implemented. Ideally, the treatment is
outlined in the guidelines or manuals. You should
supplemented with scripts and/or video. The proce-
also develop a plan to address the need for
dures may include practical examples of situations
further modifications that were not anticipated.
front-line professionals are likely to face.
For further details, see Accommodations in the

upcoming Sustainability section.
The planning team should develop

a strategy for evaluating procedural
accuracy. The goal of evaluating
procedural accuracy is to improve performance (Fixsen et al., 2005).
Procedural accuracy assessments
involve breaking down an intervention into its component parts. A list of
activities that are required for accurate
implementation is then generated.
Treatment integrity checklists can
be completed as self-assessments
(e.g., the teacher records his own
implementation behavior) or by
another professional (e.g., the school
psychologist records the teachers
implementation).
You can find some treatment
integrity checklists in books (Leaf
& McEachin, 1999) or on websites
(www.autisminternetmodules.org/
user_mod.php); please note that you
must sign in before you can access
the modules which contain implementation checklists. However, these
treatment integrity checklists may not
reflect the way your school will be
adopting an intervention. These tools
are a useful starting point, but internal
collaboration with ongoing support

from consultants is recommended
(Sanetti & Kratochwill, 2009).
All professionals will deviate from
the way they are supposed to implement an intervention from time to
time. None of us is perfect. Anyone
who has ever implemented an intervention has drifted away from the way
the treatment is supposed to be implementedeven when they are giving it
their best effort. Thats one of the reasons why treatment integrity protocols
are important. In addition to developing treatment integrity protocols,
schools can also improve procedural
accuracy by regularly reviewing the
guidelines or manuals developed by
the planning team (as discussed on
the previous page).
Development of treatment integrity
checklists and treatment guidelines
or manuals often occurs simultaneously with training (see Step 4). That
is because it is hard to develop these
tools with the level of specificity
required to answer all treatmentrelated questions until you have
sufficient training.
Step 4: Developing a Training Plan
Its all to do with training: you can do a lot if youre

properly trained.
Elizabeth II
When a school system first determines that it must address capacity issues to
implement interventions, training is often the first step considered. Hopefully, you can
now see that a great deal of work must occur before a training plan is developed. While
all these steps (previously described) are important and necessary, they do not in any
way minimize the need for a complete training plan, which is crucial for success. The
training plan should include two phases: {a} obtaining initial training and {b} providing
coaching.
Obtaining Initial Training

Unless members of the school staff have expertise in a particular treatment (e.g.,
they have completed certification in the intervention, received extensive training
in graduate school, etc.), the planning team should arrange for additional training
through outside consultants or specialists. These professionals should be able to
clearly identify the level of training necessary for the school to produce the desired
systemic changes. More complex interventions require more extensive training.
Less complex interventions will require less training time, but will still require a
great deal of attention to detail.
The literature on the training of adult learners tells us that simply engaging an
outside consultant to talk to the staff about a treatment will not result in the level of
proficiency neededeven if they provide a good deal of detail. Adults benefit from
direct training, and this should be a component of every training plan. Hands-on
training is essential.
Initial training may require multiple sessions. For example, some trainers will
progressively introduce new and more complicated strategies only after front-line
professionals have practiced skills learned in the earlier phases of training in the
actual school setting.
Developing a plan for initial training may be easier for some interventions than for
others. For example, if you are interested in Pivotal Response Training, a quick web
search leads you to the Koegel Autism Center at the University of CaliforniaSanta
Barbara. Much of the information you need about training can be accessed on this
website. You can find training materials, video clips, and the PRT certification process. In contrast, there is no single source for joint attention training. You may need
to begin by identifying a list of professionals with experience training school staff to
use behavioral strategies. You can then contact these individuals to determine their
expertise in training school staff or parents on joint attention strategies.
Coaching
If only we could develop capacity to accurately implement effective interventions
after attending a one- or two-day workshop! Unfortunately, the adult learner literature suggests this is unlikely. Didactic training alone is insufficient if the goal is to
develop a high degree of mastery in educational settings (Fixsen et al., 2005). More
experiential learning with ongoing feedback is necessary.
Coaching refers to the availability of an expert to provide on-site feedback based
on real-world application of a new treatment. The coach assesses the front-line
interventionists use of the treatment in practice, then provides feedback and
support. As noted previously, learning to implement new interventions can be
exhausting. It requires significant time and effort, and may be emotionally draining.
Good coaches provide more than constructive feedback; they also support the frontline interventionist!
Developing Timelines
Developing a plan to produce system-wide improvements in school services cannot happen overnight. In addition to developing a plan to {a} address barriers, {b} measure intended outcomes, {c}
produce a procedural guideline, and {d} establish a training plan, the planning team must produce
a timeline for developing the capacity to implement Established Treatments. Each step of the
process should be clearly tied to an expected deadline. Without a timeline, most training plans will
either be unnecessarily delayed or rushed to completion without sufficient consideration given to
accurately completing each step.
Step 5: Sustainability
Sustainability requires cooperation.

Tom Seager
The planning teams responsibilities do not end once they have developed a strategy for building capacity. The process we have described is time and labor intensive.
However, it will not produce the needed outcomes for students with ASD if efforts are
not made to sustain these system-wide changes.
We have already noted the ongoing need for training. The planning team must either
make a long-term commitment to work to sustain these changes, or develop a second
sustainability committee dedicated to this purpose.
The sustainability committee must:

Identify ongoing training needs. Even though educators have received initial training
and coaching support, the training plan should include booster training sessions.
This will increase the likelihood that school staff will implement interventions with a
high degree of procedural accuracy.
Identify resources required to address ongoing training needs and maintain a high
degree of procedural accuracy in the implementation of the intervention. The process of identifying necessary resources may evolve over time, and the sustainability
committee must establish a system for evaluating ongoing needs. It is not unusual
to discover that additional resources are necessary once a treatment is actually put
in place.
Identify new barriers to treatment implementation. The sustainability committee
must also determine if existing barriers are being addressed. Barriers may emerge
in surprising ways. Sometimes, people who like the idea of producing change in
the abstract begin resisting when the efforts required to improve service delivery
impact their daily activities.
Ensure that changes have resulted in positive outcomes for the students.
Determine how to manage requests to deviate from the procedures outlined in the
procedural guidelines/manuals. The sustainability committee must have the technical skills to either {a} ensure that procedural modifications that were not anticipated
are later addressed in a manner that is consistent with the identified treatment or
{b} identify when outside consultation is necessary.
Ongoing leadership paired with sustained ownership of the systemic changes are
necessary to meet the long-term goal of providing better educational services to all
students (Adelman & Taylor, 1997).
Accommodations
In almost all cases, a treatment
can be implemented with individual
students using exactly the same procedures which
In other cases, modifications must be made
were employed in the research that demonstrated
based on factors that are unique to the child. For
the treatment was effective. However, this does not
example, modifications may be required for a
mean that accommodations should never be made.
child with physical limitations.
As noted in Chapter 3, an educator may implement
The planning team should anticipate reasons
an intervention that does not produce favorable
for which accommodations may be necessary
results. If procedural accuracy has been calculated
and develop a plan for addressing these accom-
and the intervention has been implemented with a
modations. As noted previously, the manual or
high degree of accuracy (e.g., greater than 80%), it
guideline developed for each intervention should
becomes clear that something must be changed. In
address acceptable deviations and the exact
some cases, a different treatment may be selected.
conditions under which these accommodations
Or, school professionals may identify modifications
should be considered.
to the treatment that should be considered based

on their professional judgment and/or parental
input.
A team of school professionals with expertise

in the initial intervention and/or the proposed
accommodation can be assembled. The team
can review the proposed accommodation and
then offer support to the staff implementing the
modified treatment. The data-based approach
advocated in Chapter 3 should then be applied to
the modified treatment. In this way, an ineffective
intervention will not be maintained and a strong
rationale is provided for sustaining an
effective modification.
Unique Considerations
Each school system is unique. For example, in some parts of the country,
a single school may provide services for students of all age groups in the
region who have been diagnosed with ASD. In a different part of the country,
a school may be one of dozens serving students in a restricted age group
(e.g., elementary school).
Each of these schools may need to adapt the capacity-building strategies identified
in this chapter, based on their unique needs. For example, a large school district may
build capacity across multiple schools simultaneously. In this case, it may be necessary
to establish an internal planning team that sends representatives to a larger districtwide planning team. This schools planning team will need to collaborate with the
district-wide planning team throughout the capacity-building process. We encourage all
planning teams to identify distinctive factors and unique challenges they may face.
We hope the capacity-building example that follows clarifies the ways a school
system can meet the unique needs of its constituents while building the capacity to
implement interventions that work!
Case Study: Developing Capacity

Elizabeth Public School District
Systemic changes have been documented in educational systems using the
proposed methods outlined in this chapter. Many of these methods were
applied in the Elizabeth Public Schools (EPS) system to improve service delivery for students with ASD (Hernandez, 2008).
EPS had been sending its most challenging students with ASD to out-of-district
placement facilities. The school system made major modifications to the way it served
students on the autism spectrum starting in 2004.
EPS underwent this process in four phases:

4. Needs Identification (November 2004 May 2005)
5. Development (May 2005 August 2005)
6. Implementation (September 2005 August 2006)
7. Growth (September 2006 December 2006)
During the Needs Identification phase, school personnel reached the conclusion that
developing an ASD model classroom would be a viable option. This phase was strongly
influenced by the school systems recognition that it may not be providing the most
appropriate program to all students within the system and that effective treatment
options could be developed. The creation of a district behaviorist position increased
resources and identified a vehicle for regular input from staff regarding student needs.
In the Development phase, the school system identified a strategy for developing a
model classroom. This process included everything from budget and educational cost
considerations to evaluating staff willingness to participate in the new classroom. The
school system also addressed the need to establish clear training procedures. Training
sessions included teachers, speech-language pathologists, Child Study Team members
and administrators. A plan was established to develop capacity beyond the model
classroom and to include educators in different classrooms. This allowed the team to
focus not only on the immediate needs of students in its care, but to plan for transitioning out of the model classroom and providing services to students with different
needs.
The Implementation phase focused on the challenging realities of implementing a
complicated treatment program. As a result of good planning earlier in the process,
a consultation system was available to front-line interventionists. Not only did these
consultants provide ongoing training, but they also helped educators better address
the concerns of parents. Cultural awareness of staff was supported during this phase
because more than half of the students were from homes in which English was not
the primary language. Case managers met with staff and built a sense of solidarity as
problems were identified and solutions to barriers were addressed. During this phase,
the school system also recognized the need to plan for further growth. Staff were
trained in data collection procedures that fit smoothly into the daily activities of the
classroom. Procedural accuracy was emphasized in a supportive way.
In the Growth phase, additional classrooms were developed. Efforts were made to
continue supporting staff, being responsive to family needs, maintaining a high degree
of procedural accuracy, and recognizing the needs of individuals with ASD in the
district.
The staff identified and overcame a large number of barriers that could have delayed
or derailed their plans to implement a research-supported treatment program. By
establishing a collaborative tone, staff continued to address those barriers as effectively as possible. Although new challenges will continue to present themselves, the
school system accomplished systemic changes to support students with ASD.
You have learned that evidence-based practice requires the integration of
research findings with {a} professional judgment and data-based clinical
decision making, {b} the values and preferences of families, including the student with ASD, and {c} developing capacity to implement interventions with a
high degree of integrity. Even when everyone agrees that a given treatment is
appropriate, we are not engaging in evidence-based practice unless we can
implement an intervention accurately.
Building capacity is a complicated process, and its not easy to accurately implement Established Treatments. When necessary, we can build capacity to implement
effective interventions one child at a time. After all, we do have an obligation to use
research-supported treatments for each and every student with ASD we serve. Given
the reality of an ever-growing number of students with ASD, approaching our need to
provide treatments that work on a large-scale (systemic) basis is likely to be the most
efficient strategy.
School systems will be best served by establishing a strong team to plan for
system-wide improvements in service delivery. The team must take a systemic
approach that considers the needs of all parties involved. It must address barriers that
result from staffing concerns, and respond to the need for appropriate resources.
The team must also establish clear procedural guidelines, along with a plan to sustain
improvements.
Systemic efforts to improve services for students on the autism spectrum are possibleas demonstrated by the Elizabeth Public School District of New Jersey!
Fixsen, D. L., Naoom, S. F., Blas, K. A., Friedman,

R. M., & Wallace, F. (2005). Implementation
research: A synthesis of the literature.
Tampa, FL: Louis de la Parte Florida Mental
Health Institute Publication #231.
Sims, S. J., & Sims, R. R. (2004). Managing
school system change: Charting a course for
renewal. Greenwich, CT: Information Age
Publishing.
References}
Adelman, H. S., & Taylor, L. (1997). Toward

a scale-up model for replicating new
approaches to schooling. Journal of
Educational and Psychological Consultation,
8, 197-230.
Martens, B. K., Witt, J. C., Elliott, S. N., &

Darveaux, D. X. (1985). Teacher judgments
concerning the acceptability of school-based
interventions. Professional Psychology:
Research and Practice, 15, 191-198.
Carter, S. L. (2007). Review of treatment acceptability research. Education and Training in


4301 et seq. (2002).
Fixsen, D. L., Naoom, S. F., Blas, K. A., Friedman,

R. M., & Wallace, F. (2005). Implementation
research: A synthesis of the literature.
Tampa, FL: Louis de la Parte Florida Mental
Health Institute Publication #231.
Hertz-Picciotto, I., & Delwiche, L. (2009). The rise
in autism and the role of age at diagnosis.
Epidemiology, 20, 84-90.
Individuals with Disabilities Education
Improvement Act of 2004, Pub. L. 108-466.
Sanetti, L. M., & Kratochwill, T. R. (2009).

Treatment integrity assessment in schools:
An evaluation of the Treatment Integrity
Planning Protocol. School Psychology
Quarterly, 24, 24-35.
Sims, S. J., & Sims, R. R. (2004). Managing
school system change: Charting a course for
renewal. Greenwich, CT: Information Age
Publishing.
Appendix} The National Autism Centers

National Standards Project:
Findings and Conclusions Report
This is the full text of the Findings and Conclusions report which has been independently
distributed in this exact format.
The National Autism Centers
Findings and Conclusions

addressing the need for evidencebased practice guidelines for
autism spectrum disorders
Copyright 2009 National Autism Center

We have endeavored to build consensus among experts from diverse fields of study and theoretical
orientation. We collaboratively determined the strategies used to evaluate the literature on the
treatment of Autism Spectrum Disorders. In addition, we jointly determined the intended use of
this document. We used a systematic process to provide all of our experts multiple opportunities to
provide feedback on both the process and the document. Given the diversity of perspectives held by
our experts, the information contained in this report does not necessarily reflect the unique views
of each of its contributors on every point. We are pleased with the spirit of collaboration these
experts brought to this process.
in memory of edward g. carr, ph.d., bcba

This report is dedicated to the memory of Dr. Ted Carr, an internationally
recognized leader in the treatment of Autism Spectrum Disorders and in
the field of Positive Behavior Supports.
From the outset, Ted was a major contributor to the National
Standards Project. He played a pivotal role in shaping the methodology
used in the Project. Ted understood that the value of the National
Standards Project was based not only on the scientific validity of its
design and implementation, but also on its social validity within the
broader community. We are grateful to Ted for his insightful input, and
his persistent focus on ensuring that this document be useful to families,
educators, and service providers.
Throughout his career, Ted often led the charge for the intelligent
care and compassionate and respectful treatment of individuals with
Autism Spectrum Disorders and other developmental disabilities. We
at the National Autism Center, along with countless organizations and
professionals throughout the world, will miss him and keenly feel his loss.
vi }
Table of Contents
Acknowledgments
ix
Contributors
Introduction
1
2
About the National Standards Project. . . . . . . . . . . . . . . 1

About the National Autism Center. . . . . . . . . . . . . . . . . 2
Overview of the National Standards Project
What is the Purpose? . . . . . . . . . . . . . . . . . . . . . . 3

What was the Process? . . . . . . . . . . . . . . . . . . . . . 4
Developing a Model . . . . . . . . . . . . . . . . . . . . . 4
Identifying the Research . . . . . . . . . . . . . . . . . . . . 4
Ensuring Reliability . . . . . . . . . . . . . . . . . . . . . . 6
About the Scientific Merit Rating Scale. . . . . . . . . . . . . . 6
Treatment Effects Ratings . . . . . . . . . . . . . . . . . . . 7
Strength of Evidence Classification System . . . . . . . . . . . . 9
Outcomes
11
Established Treatments . . . . . . . . . . . . . . . . . . . . 11
Detailed Summary of Established Treatments . . . . . . . . . . . 17
Emerging Treatments . . . . . . . . . . . . . . . . . . . . . 20
Unestablished Treatments. . . . . . . . . . . . . . . . . . . 22
Ineffective/Harmful Treatments . . . . . . . . . . . . . . . . . 24
Recommendations for Treatment Selection
25
{ vii
27
29
33
Limitations
Future Directions
Future Directions for the Scientific Community . . . . . . . . . . 33

Future Directions with Methodology . . . . . . . . . . . . . . . 34
Future Directions for the National Standards Report. . . . . . . . 36
Appendix 1:
Inclusionary and Exclusionary Criteria
37
Appendix 2:
Scientific Merit Rating Scale
38
Appendix 3:
Treatment Effects
43
Appendix 4:
Treatment Target Definitions
44
Appendix 5:
Names and Definitions of Emerging and

Unestablished Treatments
45
References
49
Index
51
{ ix
Acknowledgments
There are many challenges in undertaking a project of this nature. A series of complex decisions must be made over the
course of several years that influence the usefulness of the final document. I would like to take the opportunity to thank
the extraordinary number of professionals, family members, and organizations that have made this task easier.
I have had the good fortune to receive feedback from family members and individuals on the autism spectrum at
the numerous conferences at which I have discussed the National Standards Project. Your input has influenced both
the process we have used and this final document. I hope you continue to provide us feedback as we develop future
editions of the National Standards Project. I have also received feedback at these conferences from professionals
representing different fields of expertise and theoretical orientations. These professionals grapple with the very complicated process of providing best practices in homes, schools, and communities. Thank you for your assistance and your
sustained input to the National Standards Project.
I am also grateful to the professionals and lay members of the autism community who provided very detailed feedback
at various stages of this project. It would be hard to overstate the importance of your contributions. Your disparate
views aided in the development of the review process and the completion of this document. Many of you are identified in our contributors section. I appreciate the consistent support of our expert panelists and conceptual reviewers
who contributed tirelessly throughout this process. The input of families and professionals was also essential to the
development of this project.
The National Standards Project could not have been completed without an important group of organizations and individuals. We appreciate both their willingness to underwrite the costs associated with the project and their consistent
neutrality regarding the outcomes reported in this document. May Institute has supported the National Standards
Project from its inception. Most costs associated with the first plenary session which began the development of
this project were provided by the Autism Education Network (AEN). Without the support of Michelle Waterman and
Janet Lishman of AEN, the early development of this project would have been far more challenging. Additional costs
for the project were underwritten by the California Department of Developmental Services. We also appreciate the
support and feedback we received from the Oversight and Advisory Committees through the California Department of
Developmental Services and the professionals involved in the Autism Spectrum Disorders: Guidelines for Effective
Interventions document that will be available soon.

Executive Director, National Autism Center
Chair, National Standards Project
x }
Contributors
Pilot Teams
Team 1
Gina Green, Ph.D., BCBA-D
Joseph N. Ricciardi, Psy.D., ABPP, BCBA
Team 2
Brian A. Boyd, Ph.D
Kara Anne Hume, Ph.D.
Mara V. Ladd, Ph.D.
Samuel L. Odom, Ph.D.
Hanna C. Rue, Ph.D.
Research Assistants
Statistical Consultant
Lauren E. Christian, M.A.

Jesse Logue, B.A.
Tammy Greer, Ph.D.
Document Commentators
Jennifer D. Bass, Psy.D.
Bridget Cannon-Hale, M.S.W.
Nancy DeFilippis, B.A.
Natalie DeNardo, B.A.
Marcia Eichelbeger, B.S.
Stefanie Fillers, B.A., BCABA
Mary Elisabeth Hannah, M.S.Ed., BCBA
Kerry Hayes, B.A.
Deborah Lacey
Kelli Leahy, B.A.
Linda Lotspeich, M.D.
Dana Pellitteri, B.A.
Nicole Prindeville, B.A.
Hanna C. Rue, Ph.D.
Annette Wragge, M.Ed.
We also thank a number of families who

provided input but did not wish to have
their names made public.
Computer Consultant
Jeffrey K. Oresik, M.S.
Editors
Heidi A. Howard, M.P.A.
Patricia Ladew, B.S.
Eileen G. Pollack, M.A.
Graphic Designer
Juanita Class
Advisors
Conceptual Model Reviewers
Carl J. Dunst, Ph.D.

Dean L. Fixsen, Ph.D.
Catherine E. Lord, Ph.D.
Dennis C. Russo, Ph.D., ABBP, ABPP
Brian A. Boyd, Ph.D.

Anthony J. Cuvo, Ph.D.
Ronnie Detrich, Ph.D., BCBA
Wayne W. Fisher, Ph.D.
Lauren Franke, Psy.D., CCC-SP
William Frea, Ph.D.
Lynne Gregory, Ph.D.
Penelope K. Knapp, M.D.
John R. Lutzker, Ph.D.
David McIntosh, Ph.D.
Gary Mesibov, Ph.D.
Patricia A. Prelock, Ph.D., CCC-SLP
Sally J. Rogers, Ph.D.
Mark D. Shriver, Ph.D.
Brenda Smith Myles, Ph.D.
Coleen R. Sparkman, M.A., CCC-SLP
Aubyn C. Stahmer, Ph.D., BCBA-D
Pamela J. Wolfberg, Ph.D.
John G. Youngbauer, Ph.D.
Expert Panelists
Susan M. Wilczynski, Ph.D., BCBA (Chair)
Jane I. Carlson, Ph.D., BCBA
Edward G. Carr, Ph.D., BCBA
Marjorie H. Charlop, Ph.D.
Glen Dunlap, Ph.D.
Alan E. Harchik, Ph.D., BCBA-D
Robert H. Horner, Ph.D.
Ronald Huff, Ph.D.
Lynn Kern Koegel, Ph.D., CCC-SLP
Robert L. Koegel, Ph.D.
Ethan S. Long, Ph.D., BCBA-D
Stephen C. Luce, Ph.D., BCBA-D
James K. Luiselli, Ed.D., ABPP, BCBA-D
Cathy L. Pratt, Ph.D.
Robert F. Putnam, Ph.D., BCBA
Joseph N. Ricciardi, Psy.D., ABPP, BCBA
Raymond G. Romanczyk, Ph.D., BCBA-D
Ilene S. Schwartz, Ph.D., BCBA
Tristram H. Smith, Ph.D.
Phillip S. Strain, Ph.D.
Bridget A. Taylor, Psy.D., BCBA
Susan F. Thibadeau, Ph.D., BCBA-D
Tania M. Treml, M.Ed., BCBA
{ xi
Article Reviewers
Amanda N. Adams, Ph.D., BCBA
Amanda K. Albertson, M.A.
Keith D. Allen, Ph.D., BCBA
Angela M. Arnold-Seritepe, Ph.D.
Judah B. Axe, Ph.D., BCBA
Jennifer D. Bass, Psy.D.
Barbara Becker-Cottrill, Ed.D.
Stacy Lynn Bliss Fudge, Ph.D.
Brian A. Boyd, Ph.D.
James E. Carr, Ph.D., BCBA
Stephanie Chopko, M.A.
Costanza Colombi, Ph.D.
Shannon E. Crozier, Ph.D., BCBA
Elizabeth Delpizzo-Cheng, Ph.D., BCBA, NCSP
Ronnie Detrich, Ph.D., BCBA
Melanie D. Dubard, Ph.D., BCBA
Stephen E. Eversole, Ed.D., BCBA-D
Adam B. Feinberg, Ph.D., BCBA-D
Laura F. Fisher, Psy.D.
Wayne W. Fisher, Ph.D.
William Frea, Ph.D.
William A. Galbraith, Ph.D., BCBA
Katherine T. Gilligan, M.S., BCBA
Tracy D. Guiou, Ph.D., BCABA
Neelima Gutti, B.S.
Lisa M. Hagermoser Sanetti, Ph.D.
Alan E. Harchik, Ph.D., BCBA-D
Patrick F. Heick, Ph.D., BCBA-D
Thomas S. Higbee, Ph.D., BCBA
Maree Hunt, Ph.D.
Melissa D. Hunter, Ph.D.
Heather Jennett, Ph.D., BCBA
Kristen N. Johnson-Gros, Ph.D., NCSP
Debra M. Kamps, Ph.D.
Amanda M. Karsten, M.A.
Shannon Kay, Ph.D., BCBA
Courtney L. Keegan, M.Ed., BCBA
Penelope K. Knapp, M.D.
Daniel J. Krenzer, M.S.

Mara V. Ladd, Ph.D.
Courtney M. LeClair, M.A.
Celia Lie, Ph.D.
Ethan S. Long, Ph.D., BCBA-D
James K. Luiselli, Ed.D., ABPP, BCBA-D
Elizabeth A. Lyons, Ph.D., BCBA
Gwen Martin, Ph.D., BCBA
Britney N. Mauldin, M.S.
Judy A. McCarty, Ph.D., NCSP, BCBA
J. Christopher McGinnis, Ph.D., NCSP, BCBA
Christine McGrath, Ph.D., NCSP
Victoria Moore, Psy.D.
Oliver C. Mudford, Ph.D., BCBA
Dipti Mudgal, Ph.D.
Gary M. Pace, Ph.D., BCBA-D
Heather Peters, Ph.D.
Marisa Petruccelli, Psy.D.
Katrina J. Phillips, Ph.D., BCBA
Patricia A. Prelock, Ph.D., CCC-SLP
Jane E. Prochnow, Ed.D.
Robert F. Putnam, Ph.D., BCBA
Sarah G. Reck, B.A.
Henry S. Roane, Ph.D., BCBA
Lise Roll-Peterson, Ph.D., BCBA
Hannah C. Rue, Ph.D.
Dennis C. Russo, Ph.D, ABBP, ABPP
Jana M. Sarno, M.A.

Stephanie L. Schmitz, Ed.S.
Mark D. Shriver, Ph.D.
Jennifer M. Silber, Ph.D., BCBA
Torri Smith Tejral, M.S., BCBA
Tristram H. Smith, Ph.D.
Debborah E. Smyth, Ph.D.
Aubyn C. Stahmer, Ph.D.
CarrieAnne St. Armand, M.B.A., M.S., BCBA
Ravit R. Stein, Ph.D.
Catherine E. Sumpter, Ph.D.
Bridget A. Taylor, Psy.D., BCBA
Susan F. Thibadeau, Ph.D., BCBA-D
Matthew J. Tincani, Ph.D.
Jennifer Wick, M.A.
Pamela S. Wolfe, Ph.D.
April S. Worsdell, Ph.D., BCBA
Introduction
About the National Standards Project
The National Standards Project, a primary initiative of the National Autism
Center, addresses the need for evidence-based practice guidelines for
Autism Spectrum Disorders (ASD).
The National Standards Project seeks to:
provide the strength of evidence supporting educational and behavioral treatments
that target the core characteristics of these neurological disorders
describe the age, diagnosis, and skills/behaviors targeted for improvement associated with treatment options
identify the limitations of the current body of research on autism treatment
offer recommendations for engaging in evidence-based practice for ASD
Who will benefit from national standards?

We believe that parents, caregivers, educators, and service providers who must
make complicated decisions about treatment selection will benefit from national standards.
1 } Findings and Conclusions
About the National Autism Center

The National Autism Center is dedicated to serving children and adolescents
with Autism Spectrum Disorders (ASD) by providing reliable information,promoting best practices, and offering comprehensive resources for families,
practitioners, and communities.
An advocate for evidence-based treatment approaches, the National Autism Center
identifies effective programming and shares practical information with families about
how to respond to the challenges they face. The Center also conducts applied research
as well asdevelops training and service models for practitioners. Finally, the Center
works to shape public policy concerning ASD and its treatment through the development and dissemination of national standards of practice.
Guided by a Professional Advisory Board, the Center brings concerned constituents
together to help individuals with Autism Spectrum Disorders and their families pursue
a better quality of life.
National Standards Project { 2
Overview of the National

Standards Project
What is the Purpose?
The National Standards Project serves three primary purposes:
1. To identify the level of research support currently available for educational and
behavioral interventions used with individuals (below 22 years of age)1 with Autism
Spectrum Disorders (ASD). These interventions address the core characteristics of
these neurological disorders. Knowing levels of research support is an important
component in selecting treatments that are appropriate for individuals on the autism
spectrum.
2. To help parents, caregivers, educators, and service providers understand how to
integrate critical information in making treatment decisions. Specifically, evidencebased practice involves the integration of research findings with {a} professional
judgment and data-based clinical decision-making, {b} values and preferences of
families, and {c} assessing and improving the capacity of the system to implement
the intervention with a high degree of accuracy.
3. To identify limitations of the existing treatment research involving individuals with
ASD.
We hope that the National Standards Project will help individuals with ASD, their
families, caregivers, educators, and service providers to select treatments that support
people on the autism spectrum in reaching their full potential.
1
For the purpose of this report, we use the phrase individuals with Autism Spectrum Disorders to refer to individuals on the
autism spectrum who are under 22 years of age.
What was the Process?

Developing the Model
The National Standards Project began with the development of a model for evaluating the scientific literature involving the treatment of ASD by a working group
consisting of Pilot Team 1 and outside consultation from methodologists2.The process
for the initial development of the National Standards Project is outlined in Flowchart
1. We developed a model based on an examination of evidence-based practice guidelines from other health and psychology fields3 as well as from 25 experts (see expert
panel) attending planning sessions for the National Standards Project. This model was
sent to the original experts as well as an additional 20 experts (see conceptual reviewers) who represent diverse fields of study and theoretical orientations. The model was
modified based on their feedback and then served as the foundation for data collection
procedures.
Identifying the Research

Prior to data collection, we identified the ASD treatment articles that should be
included in our review. These treatments were generally designed to address the core
features of these neurological disorders. A number of these studies also addressed the
associated features of ASD. The studies were conducted in a wide variety of settings
such as universities, university-based clinics, medical settings, and schools and were
conducted by a broad range of professionals (e.g., psychologists, speech-language
The pilot team relied on the following sources: Sidman (1960); Johnston & Pennypacker (1993); Kazdin (1982; 1998); New York
State Department of Health, Early Intervention Program (1999) and; Task Force on Promotion and Dissemination of Psychological
Procedures (1995).
2
3
These systems were developed based on an examination of previous evidence-based practice guidelines including the
Agency for Healthcare Research and Quality (West, King, Carey, Lohr, McKoy et al., 2002), American Psychological Association
Presidential Task Force on Evidence-Based Practice (2003), and the Task Force on Evidence-Based Interventions in School
Psychology (APA, 2005). These were also based on an examination of publications about evidence-based practice by authors
{a} Chambless, Baker, Baucom, Beutler, Calhoun, Crits-Christoph, et al., (1998) and {b} Horner, Carr, Halle, McGee, Odom, &
Wolery (2005).
Flowchart 1} Process of the Initial Development of the National Standards Project
Pilot Team 1 develops initial systems

for evaluating the literature
Expert panel convenes planning sessions
Develop initial version of conceptual model
Conceptual reviewers and expert

panelists review conceptual model
Modify conceptual model
Develop coding manual and coding

form based on conceptual model
Identify article reviewers
Literature search identifies

initial abstracts for consideration
Identify pilot articles
Apply inclusionary and

exclusionary criteria
Establish reliability of pilot team
Identify additional articles
Establish reliability of article reviewers
Begin articles reviews using the

Complete article reviews
Treatment categorization
Complete analysis using Strength

of Evidence Classification System
Remove articles based on

exclusionary criteria
pathologists, educators, occupational or physical therapists). Search engines produced a

total of 6,463 abstracts for consideration; an
additional 644 abstracts were identified by our
experts, attendees to national autism conferences, and project participants who reviewed
recent book chapters. These abstracts were
compared against our inclusion/exclusion
criteria (see Appendix 1). An additional 413
articles were removed by trained field reviewers (described below). We included 724
peer-reviewed articles in our final review.
Because more than one study was published
in several of these articles, a total of 775
research studies were reviewed and analyzed.
Ensuring Reliability
To ensure a high degree of agreement (i.e.,
reliability) among reviewers, the coding of
articles began with observer calibration. That
is, a pilot team reviewed articles and made
modifications to a coding manual until interobserver agreement reached an acceptable level
(>80%). All field reviewers then received a
copy of the coding manual, the coding form,
and a pilot article to code. Field reviewers
who reached an acceptable level of agreement (>80%) were invited to review articles
for the National Standards Project.
About the Scientific

Merit Rating Scale
We developed the Scientific Merit Rating
Scale as a means of objectively evaluating
whether the methods used in each study
were strong enough to determine whether or
not a treatment was effective for participants
on the autism spectrum. This information
allows us to determine if the results are
believable enough that we would expect similar results in other studies that used equal or
better research methodologies.
We then applied each of the dimensions
(listed below) included in the Scientific Merit
Rating Scale in the same way to each article.
This allowed us to consistently answer
questions relevant to the scientific merit of
each study specifically related to individuals
with ASD. Table 1 briefly describes some of
the questions answered with the Scientific
Merit Rating Scale. (A detailed outline of the
Scientific Merit Rating Scale is available in
Appendix 2.)
The five dimensions of the Scientific

Merit Rating Scale include:
1. experimental rigor of the research design;
2. quality of the dependent variable;
3. evidence of treatment fidelity;
4. demonstration of participant ascertainment; and
5. generalization data collected.
Table 1}
Examples of Questions Addressed with

the Scientific Merit Rating Scale
Rating} Scores fall between 0 and 5 with higher
scores representing higher indications of

scientific merit specific to the ASD population
Design:
Two classes of research
design were considered
Generalization
of Tx Effect(s)
Answers
questions
such as:
Answers questions such

as:
Answers questions such as:
Answers questions such as:
How many
comparisons
were made?
Was the
protocol
standardized?
What type of
measurement
was used?
Is there evidence the treatment was implemented

accurately?
Who delivered the

diagnosis?
Were objective data

collected?
How many
data points
were
collected?
What are the

psychometric
properties?
Is there
evidence of
reliability?
How much treatment fidelity

data were collected?
Was the diagnosis

confirmed?
Were maintenance
and/or generalization data collected?
Were the
evaluators
blind and/or
independent?
How much
data were
collected?
Answers
questions
such as:
How many
participants were
included?
What was
the research
design?
Participant
Ascertainment
Direct
behavioral
observation
Answers
questions
such as:
Singlesubject
Were relevant
data lost?
Measurement of
Independent Variable
Test, scale,
checklist,
etc.
Answers
questions
such as:
Group
How many
groups were
included?
Measurement of
Dependent Variable:
Two types of data were
considered
How many
participants were
included?
Is there evidence of reliability for treatment fidelity?
Were psychometrically sound

instruments used?
Were DSM or ICD
criteria used?
Were relevant
data lost?
Each category was weighted. Dimensions that have been consistently acknowledged as essential in research since the first studies were published were given
stronger weights. Factors that have most recently been considered important were
given lesser weights. The weights assigned were as follows: Research Design (.30) +
Dependent Variable (.25) + Participant Ascertainment (.20) + Procedural Integrity (.15) +
Generalization (.10).
Treatment Effects Ratings

In addition, each study was examined to determine if the treatment effects were:
{a} beneficial, {b} ineffective, {c} adverse, or {d} unknown.
Beneficial is identified when there is sufficient evidence that we can be confident
favorable outcomes resulted from the treatment.
Unknown was identified when there was not enough information to allow us to
confidently determine the treatment effects.
Ineffective is identified when there is sufficient evidence that we can be confident

favorable outcomes did not result from the
treatment.
Adverse is identified when there is sufficient evidence that the treatment was
associated with harmful effects.
Appendix 3 outlines the criteria for treatment effects.
The reason separate scores are required
to determine scientific merit and treatment
effects is they tap into separate but equally
important concerns related to each study. For
example, a study could have a very strong
research design (high scientific merit) but
show that the treatment was actually ineffective. Decision-makers should be aware of a
finding of this type.
Similarly, a study could have a relatively
weak research design (lower scientific merit)
but show that the treatment was effective.
Scientists would not necessarily believe the
treatment was actually effective in this case
because the outcomes could be due to some
factor other than the treatment (e.g., the
passage of time, some unknown variable that
was not accounted for in the study, etc.).
Once we coded all studies, we combined
the results of the Scientific Merit Rating Scale
and the Treatment Effects Ratings to identify
the level of research support that is currently
available for each educational and behavioral

intervention we examined. We identified
38 treatments4. The term treatment may
represent either intervention strategies (i.e.,
therapeutic techniques that may be used in
isolation) or intervention classes (i.e., a combination of different intervention strategies
that have core characteristics in common).
Whenever possible, we combined intervention strategies into treatment classes in
order to lend clarity to the effectiveness of
the treatment. When this was not possible,
we reported results on isolated intervention
strategies. The experts involved in the project
provided feedback when reviewing earlier
drafts of this report. That is, they were given
the opportunity to provide input three times
before the final 38 treatments were identified.
After we identified the treatments,
we applied the Strength of Evidence
Classification System criteria.
4
Reliability in the form of interobserver agreement was .92 for
treatment categorization.
Strength of Evidence Classification System

The Strength of Evidence Classification System can be used to determine how
confident we can be about the effectiveness5 of a treatment. Ratings reflect the level
of quality, quantity, and consistency of research findings for each type of intervention.
There are four categories in the Strength of Evidence Classification System.6 Table 2
identifies the criteria associated with each of the ratings.
These general guidelines can be used to interpret each of these

categories:
Established. Sufficient evidence is available to confidently determine that a treatment produces favorable outcomes for individuals on the autism spectrum. That is,
these treatments are established as effective.
Emerging. Although one or more studies suggest that a treatment produces

favorable outcomes for individuals with ASD, additional high quality studies must
consistently show this outcome before we can draw firm conclusions about treatment effectiveness.
Unestablished. There is little or no evidence to allow us to draw firm conclusions

about treatment effectiveness with individuals with ASD. Additional research may
show the treatment to be effective, ineffective, or harmful.
Ineffective/Harmful. Sufficient evidence is available to determine that a treatment

is ineffective or harmful for individuals on the autism spectrum.
5
Professionals often describe a treatment as effective when it has been shown to work in real world settings such as home,
school, and community. For the purposes of this report, the word effective refers to studies conducted in real world, clinical,
and research settings.
6
The Strength of Evidence Classification System was modified to its current four-point format to ease interpretation of outcomes for the general public. Although the Strength of Evidence Classification System was modified from a six-point format,
the interpretation of outcomes remains identical across formats. For example, all treatments that were previously identified as
having sufficient evidence of effectiveness did not vary across the two systems.
Table 2}
Strength of Evidence Classification System
Established
Emerging
Unestablished
Ineffective/Harmful
Severala published, peerreviewed studies
Fewb published, peer-reviewed

studies
May or may not be based on

research
Severala published, peerreviewed studies
Scientific Merit Rating Scales

scores of 3, 4, or 5
Beneficial treatment effects
for a specific target
These may be supplemented
by studies with lower scores
on the Scientific Merit Rating
Scale.

scores of 2
reported for one dependent
variable for a specific target
These may be supplemented
by studies with higher or lower
scores on the Scientific Merit
Rating Scale.

reported based on very poorly
controlled studies (scores of
0 or 1 on the Scientific Merit
Rating Scale)
Claims based on testimonials,
unverified clinical observations, opinions, or speculation
Ineffective, unknown, or
adverse treatment effects
reported based on poorly
controlled studies
Scientific Merit Rating Scales

scores of 3
No beneficial treatment effects
measure for a specific target
(Ineffective)
OR
Adverse treatment effects
variable for a specific target
(Harmful)
Note: Ineffective treatments are
indicated with an I and Harmful treatments are indicated
with an H
Several is defined as 2 group design or 4 single-subject design studies with a minimum of 12 participants for which there are no conflicting
results or at least 3 group design or 6 single-subject design studies with a minimum of 18 participants with no more than 1 study reporting
conflicting results. Group and single-case design methodologies may be combined.
a
b
Few is defined as a minimum of 1 group design study or 2 single-subject design studies with a minimum of 6 participants for which no
conflicting results are reported.* Group and single-subject design methodologies may be combined.
*Conflicting results are reported when a better or equally controlled study that is assigned a score of at least 3 reports either {a} ineffective
treatment effects or {b} adverse treatment effects.
Outcomes
Established Treatments
We identified 11 treatments as Established (i.e., they were established as
effective) for individuals with Autism Spectrum Disorders (ASD). Established
Treatments are those for which several well-controlled studies have shown
the intervention to produce beneficial effects. There is compelling scientific
evidence to show these treatments are effective; however, even among
Established Treatments, universal improvements cannot be expected to
occur for all individuals on the autism spectrum.
The following interventions are Established Treatments:
Antecedent Package
Behavioral Package
Comprehensive Behavioral Treatment for Young Children
Modeling
Schedules
Self-management
Each of these treatments is defined below. Whenever possible, we provided
examples of treatment strategies associated with each Established Treatment. These
examples should also be considered Established Treatments for individuals with ASD.
The number of studies conducted that contributed to this rating is listed in brackets
after the treatment name.
Established Treatments with definitions and examples:

Antecedent Package {99 studies}. These interventions involve the modification of situational events that typically precede the occurrence of a target behavior. These alterations are
made to increase the likelihood of success or reduce the likelihood of problems occurring.
Treatments falling into this category reflect research representing the fields of applied behavior analysis (ABA), behavioral psychology, and positive behavior supports.
Examples include but are not restricted to: behavior chain interruption (for increasing behaviors); behavioral
momentum; choice; contriving motivational operations; cueing and prompting/prompt fading procedures; environmental enrichment; environmental modification of task demands, social comments, adult presence, intertrial
interval, seating, familiarity with stimuli; errorless learning; errorless compliance; habit reversal; incorporating
echolalia, special interests, thematic activities, or ritualistic/obsessional activities into tasks; maintenance interspersal; noncontingent access; noncontingent reinforcement; priming; stimulus variation; and time delay.
Behavioral Package {231 studies}. These interventions are designed to reduce problem
behavior and teach functional alternative behaviors or skills through the application of basic
principles of behavior change. Treatments falling into this category reflect research representing the fields of applied behavior analysis, behavioral psychology, and positive behavior
supports.
Examples include but are not restricted to: behavioral sleep package; behavioral toilet training/dry bed training; chaining; contingency contracting; contingency mapping; delayed contingencies; differential reinforcement
strategies; discrete trial teaching; functional communication training; generalization training; mand training; noncontingent escape with instructional fading; progressive relaxation; reinforcement; scheduled awakenings; shaping;
stimulus-stimulus pairing with reinforcement; successive approximation; task analysis; and token economy.
Treatments involving a complex combination of behavioral procedures that may be listed elsewhere in this document are also included in the behavioral package category. Examples include but are not restricted to: choice +
embedding + functional communication training + reinforcement; task interspersal with differential reinforcement;
tokens + reinforcement + choice + contingent exercise + overcorrection; noncontingent reinforcement + differential
reinforcement; modeling + contingency management; and schedules + reinforcement + redirection + response
prevention. Studies targeting verbal operants also fall into this category.
Comprehensive Behavioral Treatment

for Young Children {22 studies}. This
treatment reflects research from comprehensive treatment programs that involve
a combination of applied behavior analytic
procedures (e.g., discrete trial, incidental teaching, etc.) which are delivered to
young children (generally under the age
of 8). These treatments may be delivered
in a variety of settings (e.g., home, selfcontained classroom, inclusive classroom,
community) and involve a low student-toteacher ratio (e.g., 1:1). All of the studies
falling into this category met the strict
criteria of: {a} targeting the defining
symptoms of ASD, {b} having treatment
manuals, {c} providing treatment with a
high degree of intensity, and {d} measuring
the overall effectiveness of the program
(i.e., studies that measure subcomponents
of the program are listed elsewhere in this
report).
These treatment programs may also be
referred to as ABA programs or behavioral inclusive program and early intensive
behavioral intervention.
Joint Attention Intervention {6 studies}.

These interventions involve building foundational skills involved in regulating the
behaviors of others. Joint attention often
involves teaching a child to respond to the
nonverbal social bids of others or to initiate
joint attention interactions.
Examples include pointing to objects, showing items/
activities to another person, and following eye gaze.
Modeling {50 studies}.These interventions rely on an adult or peer providing a

demonstration of the target behavior that
should result in an imitation of the target behavior by the individual with ASD.
Modeling can include simple and complex behaviors. This intervention is often
combined with other strategies such as
prompting and reinforcement.
Examples include live modeling and video modeling.

{32 studies}. These interventions involve
using primarily child-directed interactions
to teach functional skills in the natural
environment. These interventions often
involve providing a stimulating environment, modeling how to play, encouraging
conversation, providing choices and direct/
natural reinforcers, and rewarding reasonable attempts.
Examples of this type of approach include but
are not limited to focused stimulation, incidental
teaching, milieu teaching, embedded teaching,
and responsive education and prelinguistic milieu
teaching.
Peer Training Package {33 studies}.

These interventions involve teaching
children without disabilities strategies for
facilitating play and social interactions with
children on the autism spectrum. Peers
may often include classmates or siblings.
When both initiation training and peer
training were components of treatment
in a study, the study was coded as peer
training package. These interventions
may include components of other treatment packages (e.g., self-management for
peers, prompting, reinforcement, etc.).
Pivotal Response Treatment {14 studies}. This treatment is also referred to

as PRT, Pivotal Response Teaching, and
Pivotal Response Training. PRT focuses on
targeting pivotal behavioral areassuch
as motivation to engage in social communication, self-initiation, self-management,
and responsiveness to multiple cues, with
the development of these areas having
the goal of very widespread and fluently
integrated collateral improvements. Key
aspects of PRT intervention delivery also
focus on parent involvement in the intervention delivery, and on intervention in the
natural environment such as homes and
schools with the goal of producing naturalized behavioral improvements.
This treatment is an expansion of Natural Language
Paradigm which is also included in this category.
Schedules {12 studies}. These interventions involve the presentation of a task list
that communicates a series of activities or
steps required to complete a specific activity. Schedules are often supplemented by
other interventions such as reinforcement.
Schedules can take several forms including written
words, pictures or photographs, or work stations.
Common names for intervention strategies include

peer networks, circle of friends, buddy skills
package, Integrated Play Groups, peer initiation
training, and peer-mediated social interactions.
Self-management {21 studies}. These

interventions involve promoting independence by teaching individuals with ASD to
regulate their behavior by recording the
occurrence/non-occurrence of the target
behavior, and securing reinforcement for
doing so. Initial skills development may
involve other strategies and may include
the task of setting ones own goals. In
addition, reinforcement is a component of
this intervention with the individual with
ASD independently seeking and/or delivering reinforcers.
Examples include the use of checklists (using
checks, smiley/frowning faces), wrist counters,
visual prompts, and tokens.

{21 studies}. Treatments that involve a
written description of the situations under
which specific behaviors are expected to
occur. Stories may be supplemented with
additional components (e.g., prompting,
reinforcement, discussion, etc.).
Social Stories are the most well-known storybased interventions and they seek to answer the
who, what, when, where, and why in
order to improve perspective-taking.
The Established
Treatments identified
in this document arise
from diverse theoretical
orientations or fields of study.
However, certain trends emerged from
an examination of these Established Treatments.
Story-based Intervention Package) of the total
Approximately two-thirds of the Established
number of Established Treatments arose from the
Treatments were developed exclusively from the
theory of mind perspective. Interestingly, even
behavioral literature (e.g., applied behavior analy-
these interventions often included a behavioral
sis, behavioral psychology, and positive behavioral
component.
supports). Of the remaining one-third, 75% represent treatments for which research support comes
predominantly from the behavioral literature.
Additional contributions were made from the nonbehavioral literature emanating from the fields of
speech-language pathology and special education.
These researchers often gave strong emphasis to
developmental considerations. Less than 10% (i.e.,
This pattern of findings suggests that treatments

from the behavioral literature have the strongest
research support at this time. Yet it is important
to recognize that treatments based on alternative
theories, in isolation or combined with behavioral
interventions, should continue to be examined
empirically. Further, it demonstrates that all treatment studies can be compared against a common
methodological standard and show evidence
of effectiveness. Despite the preponderance of
evidence associated with the behavioral literature, it is important to acknowledge the important
contributions non-behavioral approaches are
making at present, and to fund research
examining both the behavioral and
non-behavioral literature as
we move forward.
Detailed Summary of Established Treatments

Most treatments are not intended to address every treatment target (i.e., skills to
be increased or behaviors to be decreased). Similarly, they may not be developed with
the expectation that they will target every age or diagnostic group. For example, joint
attention is a skill set that typically develops in very young children. Knowing this, we
would expect to see most of the research on joint attention conducted with infants,
toddlers, or preschool-aged children. In fact, this is exactly what our review shows.
However, whenever a treatment could reasonably be effective for different treatment
targets, age groups, or diagnostic groups, researchers should set as a goal to extend
research into these different targets or groups.
Table 3 shows which Established Treatments have demonstrated favorable outcomes for each treatment target, age group, or diagnostic group. Although not all
Established Treatments should be expected to apply to each of these areas, many of
these interventions could be applied to a broader array of treatments. A brief summary
follows.
Treatment Targets
Established Treatments have demonstrated favorable outcomes for many treatment targets. See Appendix 4 for definitions for each of the treatment targets.
Antecedent Package, Behavioral Package, and Comprehensive Behavioral Treatment for Young Children have demonstrated favorable outcomes with more
than half of the skills that are often targeted to be increased (see Table 3 for
examples).
Behavioral Package has demonstrated favorable outcomes with three-quarters of
the behaviors that are often targeted to decrease (see Table 3 for examples).
Other Established Treatments have demonstrated favorable outcomes with a
smaller range of treatment targets. In many cases, this provides a rich opportunity to extend research findings.
Age Groups
Diagnostic Groups
Established Treatments have demonstrated favorable outcomes with

many age groups.
Established Treatments have demonstrated favorable outcomes with

many diagnostic groups.
Behavioral Package has demonstrated favorable outcomes with

all age groups.
Behavioral Package, Comprehensive Behavioral Treatment for

Young Children, Joint Attention
Intervention, Modeling, Naturalistic Teaching Strategies, and Peer
Training Package have demonstrated favorable outcomes with
most diagnostic groups.
Antecedent Package, Comprehensive Behavioral Treatment for

Young Children, Modeling, and
Self-management have demonstrated favorable outcomes with
two-thirds of all age groups.
have demonstrated favorable
outcomes with one-half of all age
groups.
Only one Established Treatment
has been associated with favorable outcomes for the early adult
age group. Further investigation is
necessary for this age group.
Other Established Treatments have
demonstrated favorable outcomes
with a small range of age groups.
In many cases, this provides a rich
opportunity to extend research
findings.
A few Established Treatments

(i.e., Modeling and Story-based
Intervention Package) have been
associated with favorable outcomes for Aspergers Syndrome.
Further investigation is necessary
for this diagnostic group.
Other Established Treatments have
demonstrated favorable outcomes
with a smaller range of diagnostic
groups. In many cases, this provides a rich opportunity to extend
research findings.
Table 3}
Established Treatments with Favorable Outcomes Reported

Skills Increased
Academic
Communication
Higher Cognitive Functions
Interpersonal
Learning Readiness
Behavioral Package
Antecedent Package
Behavioral Package
CBTYC
Joint Attention
Modeling
NTS
Peer Training
PRT
CBTYC
Modeling
Antecedent Package
Behavioral Package
CBTYC
Joint Attention
Modeling
NTS
Peer Training
PRT
Self-management
Story-based
Antecedent Package
Behavioral Package
NTS
Motor
Personal Responsibility
Placement
Play
Self-Regulation
CBTYC
Antecedent Package
Behavioral Package
CBTYC
Modeling
CBTYC
Antecedent Package
Behavioral Package
CBTYC
Modeling
NTS
Peer Training
PRT
Antecedent Package
Behavioral Package
Schedules
Self-management
Story-based
Behaviors Decreased
Problem Behaviors
Restricted, Repetitive, Nonfunctional Behavior,

Interests, or Activities
Sensory/Emotional
Regulation
General Symptoms
Antecedent Package
Behavioral Package
CBTYC
Modeling
Self-management
Behavioral Package
Peer Training
Antecedent Package
Behavioral Package
Modeling
CBTYC
Ages
0-2
3-5
6-9
10-14
15-18
19-21
Behavioral
CBTYC
Joint Attention
NTS
Antecedent
Behavioral
CBTYC
Joint Attention
Modeling
NTS
Peer Training
PRT
Schedules
Self-management
Antecedent
Behavioral
CBTYC
Modeling
NTS
Peer Training
PRT
Schedules
Self-management
Story-based
Antecedent
Behavioral
Modeling
Peer Training
Schedules
Self-management
Story-based
Antecedent
Behavioral
Modeling
Self-management
Behavioral
Diagnostic Classification
Autistic Disorder
Antecedent
Behavioral
CBTYC
Joint Attention
Modeling
NTS
Peer Training
PRT
Schedules
Self-management
Story-based
Aspergers Syndrome
PDD-NOS
Modeling
Story-based
Behavioral Package
CBTYC
Joint Attention
Modeling
NTS
Peer Training
Antecedent=Antecedent Package; Behavioral=Behavioral Package; CBTYC=Comprehensive Behavioral Treatment for Young Children; Joint
Attention=Joint Attention Intervention; NTS=Naturalistic Teaching Strategies; Peer Training=Peer Training Package; PRT=Pivotal Response
Treatment; Story-based=Story-based Intervention Package
Emerging Treatments
Emerging Treatments are those for which one or more studies suggest the
intervention may produce favorable outcomes. However, additional high
quality studies that consistently show these treatments to be effective for
individuals with ASD are needed before we can be fully confident that the
treatments are effective. Based on the available evidence, we are not yet in
a position to rule out the possibility that Emerging Treatments are, in fact, not
effective.
A large number of studies fall into the Emerging level of evidence. We believe
scientists should find fertile ground for further research in these areas. The number of
studies conducted that contributed to this rating is listed in parentheses after the treatment name.
The following treatments have been identified as falling into the Emerging
level of evidence:
Augmentative and Alternative Communication Device {14 studies}
Cognitive Behavioral Intervention Package {3 studies}
Developmental Relationship-based Treatment {7 studies}
Exercise {4 studies}
Exposure Package {4 studies}
Imitation-based Interaction {6 studies}
Initiation Training {7 studies}
Language Training (Production) {13 studies}
Language Training (Production & Understanding) {7 studies}
Massage/Touch Therapy {2 studies}
Multi-component Package {10 studies}
Music Therapy {6 studies}

Peer-mediated Instructional Arrangement {11 studies}
Picture Exchange Communication System {13 studies}
Reductive Package {33 studies}
Scripting {6 studies}
Sign Instruction {11 studies}
Social Communication Intervention {5 studies}
Social Skills Package {16 studies}
Structured Teaching {4 studies}
Technology-based Treatment {19 studies}
Theory of Mind Training {4 studies}
Each of these treatments is defined in Appendix 5. Interested readers may wish to refer to the full
National Standards Report for additional details regarding these treatments.
Unestablished Treatments are those for which there is little or no evidence
in the scientific literature that allows us to draw firm conclusions about the
effectiveness of these interventions with individuals with ASD. There is no
reason to assume these treatments are effective. Further, there is no way to
rule out the possibility these treatments are ineffective or harmful.
The following treatments have been identified as falling into the
Unestablished level of evidence:
Academic Interventions {10 studies}
Auditory Integration Training {3 studies}
Facilitated Communication {5 studies}
Note: The National Standards Project followed strict inclusionary/exclusionary
criteria. As a result, we eliminated a large number of studies on the treatment
of Facilitated Communication that {a} involved adults 22 years of age or older,
{b} involved individuals with infrequently occurring co-morbid conditions, and
{c} focused on the adult facilitators (as opposed to the individuals with ASD).
Although our results indicate Facilitated Communication is an Unestablished
Treatment, we believe it is necessary to make readers aware that a number of
professional organizations have adopted resolutions advising against the use
of facilitated communication. These resolutions are often related to concerns
regarding immediate threats to the individual civil and human rights of the person with autism (American Psychological Association, 1994).
Gluten- and Casein-Free Diet {3 studies}

Note: Early studies suggested that the Gluten- and Casein-Free diet may produce favorable outcomes but did not have strong scientific designs. Better
controlled research published since 2006 suggests there may be no educational
or behavioral benefits for these diets. Further, potential medically harmful effects
have begun to be reported in the literature. We recommend reading the following
studies before considering this option:
1. Arnold, G. L., Hyman, S. L., Mooney, R. A., & Kirby, R. S. (2003). Plasma
amino acids profiles in children with autism: Potential risk of nutritional deficiencies, Journal of Autism and Developmental Disabilities, 33, 449-454.
2. Heiger, M. L., England, L. J., Molloy, C. A., Yu, K. F., Manning-Courtney, P., &
Mills, J. L. (2008). Reduced bone cortical thickness in boys with autism or
autism spectrum disorders. Journal of Autism and Developmental Disorders,
38, 848-856.
Sensory Integrative Package {7 studies}
Each of these treatments is defined in Appendix 5. Interested readers may wish to refer to the full
National Standards Report for additional details regarding these treatments.
There are likely many more treatments that fall into this category for which no research has been
conducted or, if studies have been published, the accepted process for publishing scientific work
was not followed. There are a growing number of treatments that have not yet been investigated
scientifically. These would all be Unestablished Treatments. Further, any treatments for which studies were published exclusively in non-peer-reviewed journals would be Unestablished Treatments.
Ineffective/Harmful Treatments
Ineffective or Harmful Treatments are those for which several well-controlled
studies have shown the intervention to be ineffective or to produce harmful
outcomes, respectively. At this time, there are no treatments that have sufficient evidence specific to the ASD population that meet these criteria.
This outcome is not entirely unexpected. When preliminary research findings suggest a treatment is ineffective or harmful, researchers tend to change the focus of
their scientific inquiries into treatments that may be effective. That is, research often
stops once there is a suggestion that the treatment does not work or that it is harmful. Further, research showing a treatment to be ineffective or harmful may be available
with different populations (e.g., developmental disabilities, general populations, etc.).
Ethical researchers are not going to then apply these ineffective or harmful treatments
specifically to children or adolescents on the autism spectrum just to show that the
treatment is equally ineffective or harmful with individuals with ASD.
See the Evidence-based Practice section to learn how practitioners knowledge of
interventions outside the ASD population should be integrated into the decision-making
process.
Recommendations for
Treatment Selection
Treatment selection is complicated and should be made by a team of individuals who can consider the unique needs and history of the individual with
Autism Spectrum Disorder (ASD) along with the environments in which he or
she lives. We do not intend for this document to dictate which treatments can
or cannot be used for individuals on the autism spectrum.
Having stated this, we have been asked by families, educators, and service providers to recommend how our results might be helpful to them in their decision-making.
As an effort to meet this request, we provide suggestions regarding the interpretation
of our outcomes. In all cases, we strongly encourage decision-makers to select an
evidence-based practice approach.
Research findings are not the sole factor that should be considered when treatments are selected. The suggestions we make here refer only to the research
findings component of evidence-based practice and should be only one factor considered when selecting treatments.
Recommendations based on research findings:

Established Treatments have sufficient evidence of effectiveness. We recommend
the decision-making team give serious consideration to these treatments because
{a} these treatments have produced beneficial effects for individuals involved in the
research studies published in the scientific literature, {b} access to treatments that
work can be expected to produce more positive long-term outcomes, and {c} there
is no evidence of harmful effects. However, it should not be assumed that these
treatments will universally produce favorable outcomes for all individuals on the
autism spectrum.
Given the limited research support for Emerging Treatments, we generally do not
recommend beginning with these treatments. However, Emerging Treatments
should be considered promising and warrant serious consideration if Established
Treatments are deemed inappropriate by the decision-making team. There are
several very legitimate reasons this might be the case (see examples in the
Professional Judgment or Values and Preferences sections of Chapter 5).
Unestablished Treatments either have no research support or the research that has
been conducted does not allow us to draw firm conclusions about treatment effectiveness for individuals with ASD. When this is the case, decision-makers simply do
not know if this treatment is effective, ineffective, or harmful because researchers
have not conducted any or enough high quality research. Given how little is known
about these treatments, we would recommend considering these treatments only
after additional research has been conducted and this research shows them to produce favorable outcomes for individuals with ASD.
These recommendations should be considered along with other sources of critical
information when selecting treatments (see Chapter 5).
One of the primary objectives of this document is to identify evidence-based
treatments. We are not alone in this activity. The National Standards Project
is a natural extension of the efforts of the National Research Council {2001},
the New York State Department of Health, Early Intervention Division {1999},
and other related documents produced at state and national levels.
Knowing which treatments have sufficient evidence of effectiveness is likely
toand shouldinfluence treatment selection. Evidence-based practice, however, is
more complicated than simply knowing which treatments are effective. Although we
argue that knowing which treatments have evidence of effectiveness is essential, other
critical factors must also be taken into consideration.
We have identified the following four factors of evidence-based practice:

Research Findings. The strength of evidence ratings for all treatments being
considered must be known. Serious consideration should be given to Established
Treatments because there is sufficient evidence that {a} the treatment produced
beneficial effects and {b} they are not associated with unfavorable outcomes (i.e.,
there is no evidence that they are ineffective or harmful) for individuals on the
autism spectrum.
Ideally, treatment selection decisions should involve discussing the benefits of
various Established Treatments. Despite the fact there is compelling evidence to
suggest these treatments generally produce beneficial effects for individuals on
the autism spectrum, there are reasons alternative treatments (e.g., Emerging
Treatments) might be considered. A number of these factors are listed below.
Professional Judgment. The judgment of the professionals with expertise in

Autism Spectrum Disorders (ASD) must be taken into consideration. Once treatments are selected, these professionals have the responsibility to collect data to
determine if a treatment is effective. Professional judgment may play a particularly
important role in decision-making when:
A treatment has been correctly implemented in the past and was not effective
or had harmful side effects. Even Established Treatments are not expected to
produce favorable outcomes for all individuals with ASD.
The treatment is contraindicated based on other information (e.g., the use of extra-stimulus
prompts for a child with a prompt dependency history).
A great deal of research support might be available beyond the ASD literature and should
be considered when required. For example, if an adolescent with ASD presents with
anxiety or depression, it might be necessary to identify what treatments are effective
for anxiety or depression for the general population. The decision to incorporate outside
literature into decision-making should only be made after practitioners are familiar with the
ASD-specific treatments. Research that has not been specifically demonstrated to be effective with individuals with ASD should be given consideration along with the ASD-specific
treatments only if compelling data support their use and the ASD-specific literature has not
fully investigated the treatment.
The professional may be aware of well-controlled studies that support the effectiveness
of a treatment that were not available when the National Standards Project terminated its
literature search.
Values and Preferences. The values and preferences of parents, careproviders, and the
individual with ASD should be considered. Stakeholder values and preference may play a particularly important role in decision-making when:
A treatment has been correctly implemented in the past and was not effective or had
harmful side effects.
A treatment is contrary to the values of family members.
The individual with ASD indicates that he or she does not want a specific treatment.
Capacity. Treatment providers should be well positioned to correctly implement the intervention. Developing capacity and sustainability may take a great deal of time and effort, but all
people involved in treatment should have proper training, adequate resources, and ongoing
feedback about treatment fidelity. Capacity may play a particularly important role in decisionmaking when:
A service delivery system has never implemented the intervention before. Many of these
treatments are very complex and require precise use of techniques that can only be developed over time.
A professional is considered the local expert for a given treatment but he or she actually
has limited formal training in the technique.
A service delivery system has implemented a system for years without a process in place
to ensure the treatment is still being implemented correctly.
Limitations
Like other projects of this nature, there are limitations to the National
Standards Project. Readers should be familiar with these limitations in order
to use this document most effectively.
We have indentified the following limitations:
This document focuses exclusively on research involving individuals with Autism
Spectrum Disorders (ASD) who are under 22 years of age.
This document does not include a review of the literature for children at risk
for ASD. New evidence suggests that very young children who are eventually
diagnosed with autism have a genetic predisposition that alters their interactions
with the typical learning environment.7 This area is especially important because
providing effective interventions (e.g., behavioral interventions) to these infants
may be the first critical step to altering early brain development8 so that the neural circuitry regulating social and communication functions more effectively.
This document does not include a review of the adult ASD literature.
This document is not an exhaustive review of all treatments for all individuals.
There are treatments that might have solid research support for related populations (e.g., developmental disabilities, anxiety, depression, etc.) but have limited
or no evidence of research support for individuals with ASD in the National Standards Report. See Chapter 5 for how this might influence treatment selection.
As noted in the treatment classification section of this report, determining the
categories for treatments presents a real challenge. This is equally true whenever
comprehensive reviews of the literature are completed for any diagnostic group.
Some of our experts suggested making the unit of analysis larger for some categories; others suggested making the unit of analysis smaller for most categories. In
the end, we attempted to develop categories that made sense. We expect that
Klin, A., Lin, D.J., Gorrindo, P., Ramsay, G., & Jones, W. (2009). Two-year-olds with autism orient to non-social contingencies
rather than biological motion. Nature, 1-7. doi:10.1038/nature07868.
7
Dawson, G. (2008). Early behavioral intervention, brain plasticity, and the prevention of autism spectrum disorders.
Development and Psychopathology, 20, 775-803.
8
many readers may be interested in more

detailed analysis using a smaller unit
of analysis, or data using on a different
arrangement of treatment categories
based on a larger unit of analysis.
We look forward to your feedback to
guide the next version of the National
Standards Project.
This review included an examination of
most group and single-subject research
design studies but did not include every
type of study.
For this report, we only looked
at research that was designed to
answer questions about the measurable effectiveness of an intervention
based on quantifiable data. We
did not look at research that was
designed to explore questions about
the perceived quality of an intervention or the experiences of the children
based on qualitative data.
There are studies relying on singlecase or group design methods that
were not included in this review
because they fell outside the commonly agreed-upon criteria for
evaluating the effectiveness of study
outcomes. The experts involved in
the development of these Standards
made the decision to include only
those methodologies that are generally agreed-upon by scientists as
sufficient for answering the question,
Is this treatment effective?.
We only included studies that have

been published in professional journals. It is likely that some researchers
conducted studies that provided
different or additional data that have
not been published. This could influence the reported quality, quantity, or
consistency of research findings.
When establishing interobserver agreement (IOA), field reviewers were asked
to examine the coding manual and rate
the pilot article they received. Ideally, we
would have conducted a training session
before they began rating the articles.
Also, the pilot articles were selected
randomly. Now that we have identified
articles with the highest, moderate, and
lowest ratings for both single-subject
and group research designs, we will use
these articles for establishing IOA in
future versions of the National Standards
Project.
We did not include articles reviewed
in languages other than English. This
has the potential to influence the ratings reported in this document. For
example, a study that was not included
in this review was published in French
on Integrated Play Groups (Richard
& Goupil, 2005). We hope to include
volunteer field reviewers from across
the world who can effectively review the
non-English literature in the next version
of the National Standards Project.
The National Standards Project did not evaluate the extent to which treatment
approaches have been studied in real world versus laboratory settings. We hope
to shed light on this issue in future versions of the National Standards Project.
One of the primary purposes of the National Standards Project was to identify
the level of research support currently available for a range of educational and
behavioral interventions. We did not set as our goal the determination of the level
of intensity required for delivery of these interventions. The next version of the
National Standards Project may provide further analysis in this area. In the interim,
we believe treatment providers should continue to follow the recommendations for
intensity of services provided by the National Research Council regarding children
less than 8 years of age. Specifically,
The committee recommends that educational services begin as soon as a child is suspected of having
an autistic spectrum disorder. Those services should include a minimum of 25 hours a week, 12 months
a year, in which the child is engaged in systematically planned, and developmentally appropriate educational activity toward identified objectives. What constitutes these hours, however, will vary according to a childs chronological age, developmental level, specific strengths and weaknesses, and family
needs. Each child must receive sufficient individualized attention on a daily basis so that adequate
implementation of objectives can be carried out effectively. The priorities of focus include functional
spontaneous communication, social instruction delivered throughout the day in various settings,
cognitive development and play skills, and proactive approaches to behavior problems. To the extent
that it leads to the acquisition of childrens educational goals, young children with an autistic spectrum
disorder should receive specialized instruction in a setting in which ongoing interactions occur with
typically developing children.
We argue that unless compelling reasons exist to do otherwise, intervention

services should be comprised of Established Treatments and they should be delivered following the specifications outlined in the literature (e.g., appropriate use of
resources, staff to student ratio, following the prescribed procedures, etc.).
Writing a report of this type can be quite time-consuming. The National Standards
Project terminated the literature review phase in September of 2007. Additional
studies have been published in the interim that are not reflected in the current
report. This means that if a review were conducted today, the strength of evidence ratings for a given treatment may have improved or be altered. We intend
to regularly update this document to assist decision-makers in their selection of
treatments. In the meantime, professionals should familiarize themselves with the
literature published since the fall of 2007.
Ideally, research answers important questions beyond treatment effectiveness.
This report does not review the following areas that may be important in selecting
treatments:
Cost-effectiveness;
Social validity;
Studies examining mediating or moderating variables. Mediating variables can
help explain why a treatment is effective. Moderating variables can make a difference in the likelihood a treatment is effective for a given subpopulation; and
Research supporting Established Treatments may have been developed in analog
settings (e.g., highly structured research settings), which may not reflect real
world settings accurately.
Despite its limitations, we sincerely hope this document is useful to you. We also recognize that
even more information might be helpful. For example, there may be new or different ways of organizing information that you believe could be useful. If you would like to help shape the direction of
the next version of the National Standards Project, please provide feedback to the National Autism
Center at info@nationalautismcenter.org.
Future Directions
Future Directions for the Scientific
Community
One of the goals of the National Standards Project is to identify limitations
of the existing literature base. We believe we have done so in two ways: {a}
we have identified areas benefiting from or requiring future investigation
and {b} we have developed the Scientific Merit Rating Scale and Strength of
Evidence Classification System, against which future research can be compared. We expand on these issues below.
There is room for additional research for all treatments. It will be important to
extend the current research base for Established Treatments to all reasonable treatment goals, age groups, and diagnostic groups. Additional research must be conducted
for treatments falling in the Emerging and Unestablished Treatment categories to
determine if {a} the treatments are effective and {b} the treatments are ineffective or
harmful. High quality research is perhaps most important for treatments falling into the
Unestablished Treatments category.
Future Directions with Methodology

Five dimensions were identified for the Scientific Merit Rating Scale: {a}
research design, {b} dependent variable, {c} treatment fidelity, {d} participant ascertainment, and {e} generalization (see Table 3). We identified these
dimensions based on the most recent scientific standards that are being
advocated in behavioral and social science research. However, scientific
standards change over time.
For example, there were no psychometrically sound instruments specifically
designed to diagnose Autism Spectrum Disorders (ASD) available when the earliest
studies included in this review were conducted. If there had been, the instruments
would look very different today based on changes in the diagnostic criteria over the
years. For this reason, it is not surprising that many older studies did not achieve the
highest possible ratings in this area.
Similarly, it is only recently that evidence of treatment fidelity has been consistently
emphasized by the scientific community. This means that although many studies may
do an excellent job of describing the procedures used, they still received low ratings on their ability to provide evidence that they completed all procedures exactly as
prescribed. This leaves room for improvement in the scientific literature in either the
research design or the extent to which scientists report on these important variables.
We encourage researchers to strive to meet the most rigorous standards of scientific merit in future research. We hope the Scientific Merit Rating Scale will assist them
in doing so. But it is also essential that journal editors recognize the importance of the
five dimensions of scientific merit identified in this report. Important information may
sometimes be cut from articles due to space limitations. We hope that researchers will
be able to point to the Scientific Merit Rating Scale as an example of critical information that should never be removed from scholarly work.
The Strength of Evidence Classification System may be expanded over time to
reflect additional scientific lines of inquiry. For example, it is reasonable to use alternate
criteria for different research designs, which is why we did so in the current version
of the Strength of Evidence Classification System. However, if qualitative research
is included in the next version of the National Standards Project, the current version
of the Strength of Evidence Classification System would be insufficient to accurately
evaluate these studies.
Future Directions for the National

Standards Report
We aim to address many of the limitations of the current National Standards
Report in future documents.
For example, we expect:
To review literature covering the lifespan. This will include a special section on children at risk for ASD.
To reconsider the inclusion of qualitative studies or other types of peer-reviewed
studies that are currently excluded.
To modify treatment classification based on feedback from the many experts in the
autism community.
To examine the extent to which treatments have been studied in real world
versus laboratory settings.
To add reviewers who can accurately interpret peer-reviewed articles published in
non-English journals.
With additional funding, we hope to help address questions related to cost effectiveness, social validity, studies examining mediating variables, and effectiveness of
treatments in real world settings.
We suspect that this report will raise additional questions that we hope to address
in future publications. Our ultimate goal is to answer relevant questions related to
evidence-based practice in response to the changing expectations of professionals and
the needs of families, educators, and service providers.
37 } Appendices
Appendix 1} Inclusionary and Exclusionary Criteria
Inclusionary Criteria
The National Standards Project is a systemic review of the behavioral and educational treatment literature
involving individuals with Autism Spectrum Disorders (ASD) under the age of 22. For the purposes of this
review, Autism Spectrum Disorders were defined to include Autistic Disorder, Aspergers Syndrome, and
Pervasive Developmental DisorderNot Otherwise Specified (PDD-NOS).
Exclusionary Criteria
Participants who were identified as at risk for an ASD or who were described as having autistic characteristics or a suspicion of ASD were not included in this review.
Studies were included if the treatments could have been implemented in or by school systems, including
toddler, early childhood, home-based, school-based, and community-based programs.
Studies in which parents, care providers, educators, or service providers were the sole subject of treatment
were not included in the review. If these adults were one subject but data were also available regarding
changes in child behavior or skills, the study was retained, but only those results pertaining to the childs
behavior or skills were included in the review.
Articles were only included in the review if they had been published in peer-reviewed journals.
Studies examining biochemical, genetic, and psychopharmacological treatments were excluded (see
exception below). These treatments have not historically focused on the core characteristics of ASD.
We made the decision to include curative diets because professionals are often expected to implement
curative diets across a variety of settings with a high degree of fidelity and the treatment is intended to
address the core characteristics of ASD.
Results for study participants who were diagnosed with both ASD and co-morbid conditions that do
not commonly co-occur with ASD were excluded from this review because their results could skew the
outcomes.
Articles were excluded if they did not include empirical data, if there were no statistical analyses available
for studies using group research design, if there was no linear graphical presentation of data for studies
using single-case research design, or if the studies relied on qualitative methods.
Studies were excluded if their sole purpose was to identify mediating or moderating variables.
Articles were excluded if all participants were over the age of 22 or if a study included participants both
over and under the age of 22, but separate analyses were not conducted for individuals under the age of
22. We anticipate the next version of the National Standards Project will expand the focus of the review to
include treatments involving participants across the lifespan.
Articles were excluded from the National Standards Project if they were published exclusively in languages other than English.
Findings and Conclusions: National Standards Project ( 38
Appendix 2} Scientific Merit Rating Scale
SMRS} Rating 5
Research Design
Measurement of
Dependent Variable
Group
Singlesubjecta
Test, scale,
checklist,
etc.
Direct
behavioral
observation
Number of
groups: two or
more
A minimum
of three
comparisons
of control and
treatment
conditions
Type of
measurement:
Observationbased
Type of
measurement:
continuous
or discontinuous with
calibration
data showing
low levels of
error
Design:
Random
assignment
and/or no
significant
differences
pre-Tx
Participants: n
> 10 per group
or sufficient
power for
lower number
of participants
Data Loss: no
data loss
Number of
data points
per condition:
> five
Number of
participants: >
three
Data loss:
no data loss
possible
Protocol:
standardized
Psychometric
properties
solid instrument
Evaluators:
blind and
independent
Reliability:
IOA > 90% or
kappa > .75
Percentage
of sessions:
Reliability
collected in >
25%
Type of conditions in which
data were
collected: all
sessions
Measurement of
(procedural integrity or
treatment fidelity)
Implementation accuracy
measured at > 80%
measured in 25% of total
sessions
IOA for treatment fidelity
> 80%
Participant
Ascertainment
Generalization
of Tx Effect(s)
Diagnosed
by a qualified
professional
Objective data
Diagnosis confirmed
by independent and
blind evaluators for
research purposes
using at least one
psychometrically
solid instrument
DSM or ICD
criteria or commonly
accepted criteria
during the identified
time period reported
to be met
Maintenance data
collected
AND
Generalization data
collected across
at least two of the
following: setting,
stimuli, persons
39 } Appendices
SMRS} Rating 4
Research Design
Measurement of
Dependent Variable
Group
Singlesubjecta
Test, scale,
checklist,
etc.
Direct
behavioral
observation
Number of
groups: two or
more
A minimum
of three
comparisons
of control and
treatment
conditions
Type of
measurement:
Observationbased
measurement
Type of
measurement:
continuous or
discontinuous with no
calibration
data
Design:
Matched
groups; No
significant
differences
pre-Tx; or better design
Participants: n
> 10 per group
or sufficient
power for
lower number
of participants
Data Loss:
some data
loss possible
Number of
data points
per condition:
> five
Number of
participants: >
three
Data loss:
some data
loss possible
Protocol:
standardized
Psychometric
properties
sufficient
Evaluators:
blind
OR
independent
Reliability:
IOA > 80% or
kappa > .75
Percentage
of sessions:
Reliability
collected in >
25%
data were
collected: all
sessions
Measurement of
treatment fidelity)
measured at > 80%
measured in 20% of total
session for focused interventions only
IOA for treatment fidelity:
not reported
Participant
Ascertainment
Generalization
of Tx Effect(s)
Diagnosis provided/
confirmed by
independent and
blind evaluators for
research purposes
using at least one
psychometrically
sufficient instrument
Objective data
Maintenance data
collected
AND
Generalization data
collected across
at least one of the
following: setting,
stimuli, persons
SMRS} Rating 3
Research Design
Measurement of
Dependent Variable
Group
Singlesubjecta
Test, scale,
checklist,
etc.
Direct
behavioral
observation
Number of
groups: two or
more
A minimum
of two
comparisons
of control and
treatment
conditions
Type of
measurement:
Observationbased
measurement
Type of
measurement:
continuous or
calibration
data
Design: Pre-Tx
differences
controlled
statistically or
better design
Data loss:
some data
loss possible
Number of
data points
per condition:
> three
Number of
participants:
> two
Data loss:
some data
loss possible
Protocol:
non-standardized or
standardized
Psychometric
properties
adequate
Evaluators:
neither blind
nor independent required
Reliability:
IOA > 80% or
kappa > .4
Percentage
of sessions:
Reliability
collected in >
20%
data were collected: all or
experimental
sessions only
Measurement of
treatment fidelity)
measured at > 80%
measured in 20% of partial
session for focused interventions only
not reported
Participant
Ascertainment
Generalization
of Tx Effect(s)
Diagnosis provided/
confirmed by
independent
Objective data
OR
blind evaluator for research
purposes using at
least one psychometrically adequate
instrument
OR
DSM criteria confirmed by a qualified
diagnostician or
independent and/or
blind evaluator
Maintenance data
collected
OR
Generalization data
collected across
at least one of the
following: setting,
stimuli, persons
41 } Appendices
SMRS} Rating 2
Research Design
Measurement of
Dependent Variable
Group
Singlesubjecta
Test, scale,
checklist,
etc.
Direct
behavioral
observation
Number of
groups and
Design: If two
groups, pre-Tx
difference
not controlled
or better
research
design
A minimum
of two
comparisons
of control and
treatment
conditions
Type of
measurement:
Observationbased or
subjective
Type of
measurement:
continuous or
calibration
data
OR
a one group
repeated
measures pretest/post-test
design
Data Loss:
significant
data loss
possible
Number of
data points
per Tx condition: > three
Number of
participants:
> two
Data loss: significant data
loss possible
Protocol:
non-standardized or
standardized
Psychometric
properties
modest
Evaluators:
neither blind
Reliability:
IOA > 80% or
kappa > .4
Percentage of
sessions: Not
reported
data were
collected: not
necessarily
reported
Operational
definitions are
extensive or
rudimentary
Measurement of
treatment fidelity)
Control condition is
operationally defined at an
inadequate level or better
Experimental (Tx) procedures
are operationally defined at a
rudimentary level or better
measured at > 80%
regarding percentage of
total or partial sessions: not
reported
not reported
Participant
Ascertainment
Generalization
of Tx Effect(s)
Diagnosis with at
least one psychometrically modest
instrument
Subjective data
OR
diagnosis provided
by a qualified diagnostician or blind
and/or independent
evaluator with no
reference to psychometric properties of
instrument
Maintenance data
collected
AND
Generalization data
collected across
at least 1 of the
following: setting,
stimuli, persons
SMRS} Rating 1
Research Design
Measurement of
Dependent Variable
Group
Singlesubjecta
Test, scale,
checklist,
etc.
Direct
behavioral
observation
Number of
groups and
Design:
two group,
post-test
only or better
research
design
A minimum
of two
comparisons
of control and
treatment
conditions
Type of
measurement:
Observationbased or
subjective
Type of
measurement:
continuous or
calibration
data
OR
retrospective
comparison of
one or more
matched
groups
Number of
participants:
> one
Protocol:
non-standardized or
standardized
Data loss: significant data

loss possible
Psychometric
properties
weak
Evaluators:
Neither blind
Data loss:
significant
data loss
possible

data were
collected: not
necessarily
reported
Measurement of
treatment fidelity)
Participant
Ascertainment
Generalization
of Tx Effect(s)
Control condition is
operationally defined at an
inadequate level or better
Diagnosis provided
by {a} review of
records
Experimental (Tx) procedures

are operationally defined at a
rudimentary level or better
OR
Subjective
or subjective
supplemented with
objective data
IOA and procedural fidelity

data are unreported
{b} instrument with

weak psychometric
support
Maintenance data
collected
OR
Generalization data
collected across
at least one of the
following: setting,
stimuli, persons
Operational
definitions are
extensive or
rudimentary
SMRS} Rating 0
Does not meet
criterion for a
score of 1
Does not meet

criterion for a
score of 1
Does not meet

criterion for a
score of 1
Does not meet

criterion for a
score of 1
Does not meet criterion for a

score of 1
Does not meet

criterion for a score
of 1
Does not meet

criterion for a score
of 1
For all designs except alternating treatments design (ATD). For an ATD, the following rules apply:
{5} Comparison of baseline and experimental condition; > five data points per experimental condition, follow-up data collected, carryover effects minimized through counterbalancing of key variables (e.g., time of day), and condition discriminability; n > three; no data loss
{4} Comparison of baseline and experimental condition; > five data points per experimental condition; carryover effects minimized through counterbalancing of key variables (e.g., time of day), OR condition discriminability; n > three; some data loss possible
{3} > five data points per condition, carryover effects minimized counterbalancing of key variables OR condition discriminability; n > two; some data loss
possible
{2} > five data points per condition; n > two; significant data loss possible
{1} > five data points per condition; n > one; significant data loss possible
{0} Does not meet criterion for a score 1
43 } Appendices
Appendix 3} Treatment Effects
Beneficial Treatment
Effects Reported
Single:
A functional relation is established and is replicated at least
two times
Unknown Treatment
Effects Reported
For all research designs:
The nature of the data does not
allow for firm conclusions about
whether the treatment effects
are beneficial, ineffective, or
adverse
Ineffective Effects Reported

Single:
A functional relation was not established and
{a} results were not replicated but at
least two replications were attempted
{b} a minimum of five data points were
collected in baseline and treatment
conditions
{c} a minimum of two participants
were included
Adverse Treatment
Effects Reported
Single:
A functional relation is established and is replicated at least
two times
The treatment resulted in
greater deficit or harm on the
dependent variable based
on a comparison to baseline
conditions
{d} a fair or good point of comparison

(e.g., steady state) existed
ATD:
Moderate or strong separation
between at least two data
series for most participants
Carryover effects were
minimized
ATD:
No separation was reported and
baseline data show a stable pattern of
responding during baseline and treatment conditions for most participants
ATD:
Moderate or strong separation
between at least two data
series for most participants
Carryover effects were
minimized
A minimum of five data points
per condition
A minimum of five data points

per condition
Treatment conditions showed

the treatment produced greater
deficit or harm for most or all
participants when compared to
baseline
Group:
Statistically significant effects
reported in favor of the
treatment
Group:
No statistically significant effects were
reported with sufficient evidence an
effect would likely have been found*
*The criterion includes: {a} there was
sufficient power to detect a small
effect {b} the type I error rate was
liberal, {c} no efforts were made to
control for experiment-wise Type I
error rate, and {d} participants were
engaged in treatment
Group:
Statistically significant finding
reported indicating a treatment
resulted in greater deficit or
harm on any of the dependent
variables
Appendix 4} Treatment Target Definitions
Skills Targeted for Increase

Academic
Tasks required for success with school activities
Communication
Tasks that involve nonverbal or verbal methods of
sharing experiences, emotions, information
Higher Cognitive Functions
Tasks that require complex problem-solving skills
outside the social domain
Interpersonal
Tasks that require social interaction with one or
more individuals
Learning Readiness
Tasks that serve as the foundation for successful
mastery of complex skills in other domains
Personal Responsibility
Tasks that involve activities embedded into everyday routines
Placement1
Identification of a placement into a particular
setting
Play
Tasks that involve non-academic and non-work
related activities that do not involve self-stimulatory behavior or require interaction with other
people
Self-Regulation
Tasks that involve the management of ones own
behaviors in order to meet a goal
Motor Skills
Tasks that require coordination of muscle systems
to produce a specific goal involving either fine
motor or gross motor skills
Skills Targeted for Decrease

General Symptoms
General Symptoms includes a combination of symptoms that may be directly associated with ASD or may be a
result of psychoeducational needs that are sometimes associated with ASD
Problem Behaviors
Behaviors that can be harmful to the individual or others, result in damage to objects, or interfere with the
expected routines in the community
Restricted, Repetitive, Nonfunctional patterns of behavior, interests, or activity (RRN)
Limited, frequently repeated, maladaptive patterns of motor activity, speech, and thoughts
Sensory or Emotional Regulation (SER)
Sensory and emotional regulation refers to the extent to which an individual can flexibly modify his or her level
of arousal or response to function effectively in the environment
Although placement is not a skill, it represents an important accomplishment toward which intervention programs strive.
45 } Appendices
Appendix 5} Names and Definitions of Emerging and

Emerging Treatments
Augmentative and Alternative
Communication Device (AAC)
These interventions involved the use of high
or low technologically sophisticated devices
to facilitate communication. Examples
include but are not restricted to: pictures,
photographs, symbols, communication books,
computers, or other electronic devices.
Cognitive Behavioral Intervention Package
These interventions focus on changing everyday negative or unrealistic thought patterns
and behaviors with the aim of positively influencing emotions and/or life functioning.
Developmental Relationship-based Treatment
These treatments involve a combination of
procedures that are based on developmental
theory and emphasize the importance of building social relationships. These treatments
may be delivered in a variety of settings (e.g.,
home, classroom, community). All of the studies falling into this category met the strict
criteria of: {a} targeting the defining symptoms of ASD, {b} having treatment manuals,
{c} providing treatment with a high degree
of intensity, and {d} measuring the overall
effectiveness of the program (i.e., studies that
measure subcomponents of the program are
listed elsewhere in this report). These treatment programs may also be referred to as the
Denver Model, DIR (Developmental, Individual
Differences, Relationship-based)/Floortime,
Relationship Development Intervention, or
Responsive Teaching.
Exercise
These interventions involve an increase in
physical exertion as a means of reducing
problems behaviors or increasing appropriate
behavior.
Exposure Package
These interventions require that the individual
with ASD increasingly face anxiety-provoking
situations while preventing the use of maladaptive strategies used in the past under
these conditions.
Imitation-based Interaction
These interventions rely on adults imitating
the actions of a child.
Initiation Training
These interventions involve directly teaching
individuals with ASD to initiate interactions
with their peers.
Language Training (Production)
These interventions have as their primary
goal to increase speech production. Examples
include but are not restricted to: echo relevant
word training, oral communication training,
oral verbal communication training, structured
discourse, simultaneous communication, and
individualized language remediation.
Language Training (Production &

Understanding)
These interventions have as their primary
goals to increase both speech production
and understanding of communicative acts.
Examples include but are not restricted to:
total communication training, position object
training, position self-training, and language
programming strategies.
Massage/Touch Therapy
These interventions involve the provision of
deep tissue stimulation.
Multi-component Package
These interventions involve a combination of
multiple treatment procedures that are derived
from different fields of interest or different
theoretical orientations. These treatments do
not better fit one of the other treatment packages in this list nor are they associated with
specific treatment programs.
Music Therapy
These interventions seek to teach individual
skills or goals through music. A targeted skill
(e.g., counting, learning colors, taking turns,
etc.) is first presented through song or rhythmic cuing and music is eventually faded.
Peer-mediated Instructional Arrangement
These interventions involve targeting academic skills by involving same-aged peers in
the learning process. This approach is also
described as peer tutoring.
Picture Exchange Communication System

This treatment involves the application of a
specific augmentative and alternative communication system based on behavioral principles
that are designed to teach functional communication to children with limited verbal and/or
communication skills.
Reductive Package
These interventions rely on strategies
designed to reduce problem behaviors in the
absence of increasing alternative appropriate behaviors. Examples include but are not
restricted to water mist, behavior chain interruption (without attempting to increase an
appropriate behavior), protective equipment,
and ammonia.
Scripting
These interventions involve developing a
verbal and/or written script about a specific
skill or situation which serves as a model for
the child with ASD. Scripts are usually practiced repeatedly before the skill is used in the
actual situation.
Sign Instruction
These interventions involve the direct teaching
of sign language as a means of communicating with other individuals in the environment.
47 } Appendices
Social Communication Intervention

These psychosocial interventions involve
targeting some combination of social communication impairments such as pragmatic
communication skills, and the inability to
successfully read social situations. These
treatments may also be referred to as social
pragmatic interventions.
Social Skills Package
These interventions seek to build social interaction skills in children with ASD by targeting
basic responses (e.g., eye contact, name
response) to complex social skills (e.g., how to
initiate or maintain a conversation).
Structured Teaching
Based on neuropsychological characteristics
of individuals with autism, this intervention
involves a combination of procedures that rely
heavily on the physical organization of a setting, predictable schedules, and individualized
use of teaching methods. These procedures
assume that modifications in the environment,
materials, and presentation of information can
make thinking, learning, and understanding
easier for people with ASD if they are adapted
to individual learning styles of autism and
individual learning characteristics. All of the
studies falling into this category met the strict
criteria of: {a} targeting the defining symptoms of ASD; {b} having treatment manuals;
{c} providing treatment with a high degree
of intensity; and {d} measuring the overall
effectiveness of the program (i.e., studies that
measure subcomponents of the program are
listed elsewhere in this report). These treatment programs may also be referred to as
TEACCH (Treatment and Education of Autistic
and related Communication-handicapped
CHildren).
Technology-based Treatment
These interventions require the presentation
of instructional materials using the medium of
computers or related technologies. Examples
include but are not restricted to Alpha Program, Delta Messages, the Emotion Trainer
Computer Program, pager, robot, or a PDA
(Personal Digital Assistant). The theories
behind Technology-based Treatments may vary
but they are unique in their use of technology.
Theory of Mind Training
These interventions are designed to teach
individuals with ASD to recognize and identify mental states (i.e., a persons thoughts,
beliefs, intentions, desires and emotions) in
oneself or in others and to be able to take the
perspective of another person in order to predict their actions.
Academic Interventions
These interventions involve the use of traditional teaching methods to improve academic performance.
Examples include but are not restricted to: personal instruction; paired associate; picture-to-text
matching; The Expression Connection; answering pre-reading questions; completing cloze sentences;
resolving anaphora; sentence combining; special education; speech output and orthographic feedback; and handwriting training.
Auditory Integration Training
This intervention involves the presentation of modulated sounds through headphones in an attempt to
retrain an individuals auditory system with the goal of improving distortions in hearing or sensitivities
to sound.
Facilitated Communication
This intervention involves having a facilitator support the hand or arm of an individual with limited
communication skills, helping the individual express words, sentences, or complete thoughts by using a
keyboard of words or pictures or typing device.
Gluten- and Casein-Free Diet
These interventions involve elimination of an individuals intake of naturally occurring proteins gluten
and casein.
Sensory Integrative Package
These treatments involve establishing an environment that stimulates or challenges the individual to
effectively use all of their senses as a means of addressing overstimulation or understimulation from
the environment.
49 } References
References}

2009).
Report of the Task Force on EvidenceBased Interventions in School Psychology.
Available at http://www.sp-ebi.org/
documents/_workingfiles/EBImanual1.pdf
(assessed March 4, 2009).
Report of the 2005 Presidential Task Force
on Evidence-Based Practice. Available at
http://www.apa.org/practice/ebpreport.pdf
(accessed March 4, 2009).
Arnold, G. L., Hyman, S. L., Mooney, R. A., & Kirby,
R. S. (2003). Plasma amino acids profiles in
children with autism: Potential risk of nutritional deficiencies. Journal of Autism and
Developmental Disabilities, 33, 449-454.
Chambless, D.L., Baker, M.J., Baucom, D.H.,
Beutler, L., Calhoun, K.S., Crits-Christoph,
P. et al. (1998). Update on empirically
validated therapies: II. The Clinical
Psychologist, 51(1), 3-16.
Dawson, G. (2008). Early behavioral intervention, brain plasticity, and the prevention of
autism spectrum disorders. Development
and Psychopathology, 20, 775-803.
Heiger, M. L., England, L. J., Molloy, C. A., Yu,
K. F., Manning-Courtney, P., & Mills, J. L.
(2008). Reduced bone cortical thickness in
boys with autism or autism spectrum disorders. Journal of Autism and Developmental
Disorders, 38, 848-856.
Horner, R., Carr, E., Halle, J., McGee, G., Odom,
S., & Wolery, M. (2005). The use of singlesubject research to identify evidence-based
practice in special education. Exceptional
Children, 71(2), 165-179.
Johnston, J. M. & Pennypacker, H. S. (1993).
Strategies and tactics of behavioral
research (2nd ed.). New Jersey: Lawrence
Erlbaum Associates.
Kazdin, A. E. (1982). Single-case research designs:
Methods for clinical and applied settings.
New York: Oxford University Press.
Kazdin, A. E. (1998). Methodological issues and
strategies in clinical research (2nd ed.).
Washington, DC: American Psychological
Association.
Klin, A., Lin, D. J., Gorrindo, P., Ramsay, G., &

Jones, W. (2009). Two-year-olds with
autism orient to non-social contingencies
rather than biological motion. Nature, 1-7.
doi:10.1038/nature07868.
National Research Council (2001). Educating
children with autism. Committee on
Educational Interventions for Children With
Autism, Division of Behavioral and Social
Sciences and Education. Washington, DC:
National Academy Press.
New York State Department of Health Early
Intervention Program (1999). Clinical
practice guideline: Report of the recommendations. Autism/Pervasive developmental
disorders, assessment and intervention for
young children (age 0-3 years). Albany, NY:
New York State Department of Health Early
Intervention Program.
Richard, V. & Goupil, G. (2005). Application des
groupes de jeux integres aupres deleves
ayant un trouble envahissant du development (Implementation of Integrated Play
Groups with PDD Students). Revue quebecoise de psychologie, 26(3), 79-103.
Sidman, M. (1960). Tactics of scientific research:

Evaluating experimental data in psychology.
New York: Basic Books, Inc.
Task Force on Promotion and Dissemination of
Psychological Procedures (1995). Training in
and dissemination of empirically-validated
psychological treatments: Report and recommendations. The Clinical Psychologist,
48, 3-23.
West, S., King, V., Carey, T.S., Lohr, K.N., McKoy,
N. et al. (2002). Systems to rate the
strength of scientific evidence. Evidence
Report/Technology Assessment No. 47.
(Prepared by the Research Triangle InstituteUniversity of North Carolina Evidence-Based
Practice Center under Contract No. 29097-0011. AHRQ Publication No. 02-E016.)
Rockville, Md: Agency for Healthcare
Research and Quality.
51 } Index
Index}
Treatment Names
A
Academic Interventions 22, 48
C
Chaining 12
Choice 12, 14
Early Intensive Behavioral Intervention 13
Alpha Program 47
Circle of Friends 14
Echolalia (incorporating into tasks) 12
Ammonia 46
Cognitive Behavioral Intervention

Package 20, 45
Echo Relevant Word Training 45
Adult Presence (environmental

modifications of) 12
Answering Pre-reading Questions 48

Antecedent Package 11, 12, 17, 18, 19
Completing Cloze Sentences 48
Applied Behavior Analysis (ABA) 12, 13
Comprehensive Behavioral Treatment for

Young Children 11, 13, 17, 18, 19
Auditory Integration Training 22, 48
Contingency Contracting 12
Augmentative and Alternative

Communication Device 20, 45
Contingency Mapping 12
Contriving Motivational Operations 12
B
Behavioral Inclusive Program 13
Behavioral Momentum 12
Behavioral Package 11, 12, 17, 18, 19
Behavioral Sleep Package 12
Behavioral Toilet Training/Dry Bed
Training 12
Cueing 12
Embedded Teaching 14
Emotion Trainer Computer Program 47
Environmental Enrichment 12
Errorless Compliance 12
Errorless Learning 12
Exercise 12, 20, 45
Exposure Package 20, 45
Expression Connection 48
D
Delayed Contingencies 12
Delta Messages 47
Developmental, Individual Differences,
Relationship-based 45
Behavior Chain Interruption 12, 46
Developmental Relationship-based
Treatment 20, 45
Buddy Skills Package 14
Differential Reinforcement Strategies 12
F
Facilitated Communication 22, 48
Familiarity with Stimuli (environmental
Floortime 45
Focused Stimulation 14
Functional Communication Training 12
Discrete Trial Teaching 12

Dry Bed Training 12
G
Generalization Training 12
Gluten- and Casein-Free 23, 48
H
Habit Reversal 12
Handwriting Training 48
Maintenance Interspersal 12
Mand Training 12
Massage/Touch Therapy 20, 46
Imitation-based Interaction 20, 45
Milieu Teaching 14
Incidental Teaching 13, 14
Modeling 11, 13, 18, 19
Individualized Language Remediation 45
Multi-component Package 20, 46
Initiation Training 14, 20, 45
Music Therapy 21, 46
Integrated Play Groups 14, 30, 50

Intertrial Interval 12
J
Joint Attention Intervention 11, 13, 18, 19
L
Language Programming Strategies 46
Language Training (Production) 20, 45
Language Training (Production &
Understanding) 20, 46
Live Modeling 13
N
Naturalistic Teaching Strategies 11, 14,
18, 19
P
Pager 47
Paired Associate 48
PDA (Personal Digital Assistant) 47
Peer Initiation Training 14
Peer-mediated Instructional
Arrangement 21, 46
Peer-mediated Social Interactions 14
Peer Networks 14
Peer Training Package 11, 14, 18, 19
Peer Tutoring 46
Natural Language Paradigm 14
Personal Instruction 48
Noncontingent Access 12
Picture Exchange Communication

System 21, 46
Noncontingent Escape with Instructional

Fading 12
Noncontingent Reinforcement 12
Picture-to-Text Matching 48
Pivotal Response Treatment 11, 14, 19
Position Object Training 46
O
Oral Communication Training 45
Oral Verbal Communication Training 45
Position Self-training 46
Priming 12
Progressive Relaxation 12
Prompting/Prompt Fading Procedures 12
Protective Equipment 46
53 } Index
Reductive Package 21, 46
Task Analysis 12
Reinforcement 12, 13, 14, 15
Task Demands (environmental modifications

of) 12
Relationship Development Intervention 45

Resolving Anaphora 48
Responsive Education and Prelinguistic
Milieu Teaching 14
TEACCH (Treatment and Education of

Autistic and related Communicationhandicapped CHildren) 47
Responsive Teaching 45
Technology-based Treatment 21, 47
Ritualistic/Obsessional Activities 12
Thematic Activities 12
Theory of Mind Training 21, 47
S
Scheduled Awakenings 12
Schedules 11, 12, 14, 19, 47
Scripting 21, 46
Seating (environmental modifications
of) 12
Self-management 11, 14, 15, 19
Sensory Integrative Package 23, 47, 48
Time Delay 12
Special Interests (incorporating into
tasks) 12
Speech Output and Orthographic
Feedback 48
Stimulus-Stimulus Pairing with
Reinforcement 12
Stimulus Variation 12
Sentence Combining 48
Story-based Intervention Package 11, 15,

16, 18, 19
Shaping 12
Structured Discourse 45
Sign Instruction 21, 46
Structured Teaching 21, 47
Simultaneous Communication 45
Successive Approximation 12
Social Comments (environmental

Social Communication Intervention 21, 47
Social Skills Package 21, 47
Social Stories 15
Special Education 48, 49
Token Economy 12
Total Communication Training 46
V
Video Modeling 13
Visual Prompts 15
W
Water Mist 46

Phone
Fax
877 - 313 - 3833

781 - 437 - 1401
2009 National Autism Center
Email
Web
info@nationalautismcenter.org
www.nationalautismcenter.org

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Evidence-Based Practice

Autism in the Schools

Copyright 2009 National Autism Center

The Importance of Evidence-based Practice. . . . . . . . . . . . . . . . . . .

Understanding Autism Spectrum Disorders

Defining and Diagnosing Autism Spectrum Disorders. . . . . . . . . . . . . . . 13

Bipolar Disorder and Oppositional Defiant Disorder . . . . . . . . . . . .

Research Findings of the National Standards Project

Joint Attention Intervention. . . . . . . . . . . . . . . . . . . . . . . . . 48

Naturalistic Teaching Strategies. . . . . . . . . . . . . . . . . . . . . . . 52

Professional Judgment and Data-based Decision Making

Integrating Information About the Student . . . . . . . . . . . . . . . . . . . . 74

Setting Goals and Defining Target Behaviors. . . . . . . . . . . . . . . . . . . 80

Visual Analysis of Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Incorporating Family Preferences and Values

Supporting Family Involvement in Evidence-based Practice. . . . . . . . . . . . 113

Socioeconomic Status. . . . . . . . . . . . . . . . . . . . . . . . . . . 116

School Factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

Recommendations for Incorporating Family Preferences and Values. . . . . . . .

Ongoing Communication . . . . . . . . . . . . . . . . . . . . . . . . . 131

Inform Families of Choices and Options. . . . . . . . . . . . . . . . . . . 134

Establish Appropriate Family Supports . . . . . . . . . . . . . . . . . . . 136

Case Example . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

Building and Sustaining Capacity to Deliver Treatments

Producing Systemic Change . . . . . . . . . . . . . . . . . . . . . . . . . 148

Step 2: Problem Clarification and Needs Assessment . . . . . . . . . . . . . 154

Step 4: Developing a Training Plan. . . . . . . . . . . . . . . . . . . . . 172

Findings and Conclusions of the National Standards Project

Susan M. Wilczynski, Ph.D., BCBA

Eileen G. Pollack, M.A.

National Autism Center

National Autism Center

Findings and Conclusions report.)

1 } Evidence-based Practice and Autism in the Schools

These factors include:

About our Terminology:

National Autism Center { 2

Chapter 2} Research Findings

3 } Evidence-based Practice and Autism in the Schools

Chapter 3} Professional Judgment

National Autism Center { 4

Like other evidence-based practice guidelines, the National Standards Project

seek out more detailed information in the

5 } Evidence-based Practice and Autism in the Schools

Chapter 4} Values and Preferences of Families

National Autism Center { 6

begin the intervention without directly

To expand your use of strategies for

There are many barriers that could

7 } Evidence-based Practice and Autism in the Schools

Lets say your school makes the

implemented with more children with ASD

or a school) and the groups for which the

Before beginning training, a needs

National Autism Center { 8

Appendix} Findings and Conclusions of the

9 } Evidence-based Practice and Autism in the Schools

American Psychological Association (1994).

National Autism Center { 10

11 } Evidence-based Practice and Autism in the Schools

National Autism Center { 12

Defining and Diagnosing Autism

13 } Evidence-based Practice and Autism in the Schools